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ORIGINAL ARTICLE
Year : 2018  |  Volume : 18  |  Issue : 3  |  Page : 119-123

Retrospective study of results of closed tibial diaphyseal fractures treated by closed interlocking nail by subjective and objective parameters


Department of Orthopedics, Burdwan Medical College, Bardhaman, West Bengal, India

Date of Web Publication6-Nov-2019

Correspondence Address:
Soumyadeep Duttaroy
Burdwan Medical College, Room No-11, J R Hostel, Bardhaman - 713 104, West Bengal
India
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DOI: 10.4103/sjsm.sjsm_30_17

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  Abstract 

Background: Intramedullary nailing of tibia fulfills the objective of stable fixation with minimal tissue damage resulting in early fracture union. However, it is accompanied by its own set of complications.
Materials and Methods: Study area: Burdwan Medical College and Hospital. Study population: Patients attending emergency room and outpatient department 18 years with closed tibial diaphyseal fractures. Sample size: Fifty patients. Study Design: This study was an institution-based retrospective, observational study.
Parameters to be Studied: (1) Subjective parameters: (A) resumption of activities of daily living, (B) pain-free movement and walking, and (C) squatting and sitting cross-legged. (2) Objective parameters: (A) clinical (i) weight-bearing time (partial/complete), (ii) clinical union time, (iii) range of motion of knee and ankle, (iv) limb length discrepancy, (v) neurovascular damage, (vi) infection, and (vii) need for second surgery: (a) dynamization, (b) exchange nailing, (c) bone grafting, and (d) ORIF with plate and bone grafting. (B) radiological: (i) radiological union, (ii) varus/valgus, (iii) procurvatum/recurvatum, (iv) rotational malalignment, and (v) implant failure.
Results: Final outcome was measured using Johner and Wruhs' Criteria with modification, and excellent result was achieved in 48% patients, good in 34% patients, fair in 12% patients and poor in 6% patients.
Conclusion: Closed interlocking nail for closed tibial diaphyseal fractures of tibia is not a “full-proof” technique. Advantages over conservative methods and it's complications, both should be explained, and an informed consent taken before “interlocking” a closed tibial diaphyseal fracture.

Keywords: Conservative treatment, interlocking nail, tibial diaphyseal fractures


How to cite this article:
Sarkar A, Ray MK, Chatterjee B, Duttaroy S, Islam S, De C. Retrospective study of results of closed tibial diaphyseal fractures treated by closed interlocking nail by subjective and objective parameters. Saudi J Sports Med 2018;18:119-23

How to cite this URL:
Sarkar A, Ray MK, Chatterjee B, Duttaroy S, Islam S, De C. Retrospective study of results of closed tibial diaphyseal fractures treated by closed interlocking nail by subjective and objective parameters. Saudi J Sports Med [serial online] 2018 [cited 2019 Nov 18];18:119-23. Available from: http://www.sjosm.org/text.asp?2018/18/3/119/270319




  Introduction Top


Closed intramedullary nailing of tibia became an accepted treatment for closed tibial shaft fractures during the ninth decade (Höntzsch D, Weller S, Perren SM).[1] The intramedullary nailing under image intensifier with proximal and distal locking fulfills the objective of stable fixation with minimal tissue damage resulting in better and quicker fracture unions allowing early mobilization.[2] However, it comes at the cost of its own set of complications.

The present study has been undertaken to retrospectively review the results of closed tibial diaphyseal fractures treated by closed intramedullary interlocking nailing by subjective and objective parameters.


  Materials and Methods Top


Study area

Burdwan Medical College and Hospital.

Study population

All patients attending orthopedic emergency room and outpatient department above 18 years of age with closed tibial diaphyseal fractures.

Exclusion criteria

Pathological fractures, open fractures, and patients having neurological and vascular injuries.

Sample size

Fifty patients.

Study design

This study was an institution-based retrospective, unbiased, and observational study.

Parameters to be studied

  1. Subjective parameters


    1. Resumption of activities of daily living
    2. Pain-free movement and walking
    3. Squatting and sitting cross-legged


  2. Objective parameters


    1. Clinical


      1. Weight-bearing time (partial/complete)
      2. Clinical union time
      3. Range of motion of knee and ankle
      4. Limb length discrepancy
      5. Neurovascular damage
      6. Infection
      7. Need for second surgery


      1. Dynamization
      2. Exchange nailing
      3. Bone grafting
      4. ORIF with plate and bone grafting


    2. Radiological


      1. Radiological union
      2. Varus/valgus
      3. Procurvatum/recurvatum
      4. Rotational malalignment
      5. Implant failure.


Study technique

Final results were evaluated using Johner and Wruhs' Criteria [3] [Annexure 1].



Analysis of data

The results were analyzed by appropriate statistical tests using Microsoft Excel (2016, Microsoft Corporation, One Microsoft Way, Redmond, WA 98052-6399, USA), Statistica version 6 (TIBCO Software Inc., Round Rock, Texas, USA) and GraphPad Prism version 6 software (GraphPad Software, 2365 Northside Dr., Suite 560, San Diego, CA 92108, USA).


  Results and Analyses Top


Majority of the patients in this study were between age group 21-30 years, with mean age of (33.16 ±13.06) years [Table 1] and majority being males(76%) [Table 2]. Majority of fractures were of 42A type (70%), out of which 38% were simple oblique (42A2) [Table 3]. Maximum number of patients were operated within 3-7 days interval (48%, n = 24) in this study with 64% patients operated with one week of injury (Mean -6.65 ± 4.93 days) [Table 4].
Table 1: Distribution of study population according to age

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Table 2: Distribution of study population according to sex

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Table 3: Distribution of study population according to fracture pattern [Orthopaedic Trauma Association (OTA)/Arbeitsgemeinschaft für Osteosynthesefragen (AO) Classification]

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Table 4: Injury-surgery interval

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About 22% of patients were allowed partial weight bearing within 2 weeks and 74% within 4 weeks (Mean, 3.74 ± 1.56 weeks) [Table 5]. This is comparatively earlier than Maruthi CV and Shivanna's [4] study where only 50% patients were allowed partial weight bearing by 4th week.
Table 5: Time of partial weight bearing

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In this study, 38% patients (n = 19) started full weight bearing by 12 weeks following surgery and 80% (n = 40) by 16 weeks [Table 6]. In 50% cases (n = 25), clinical union was achieved within 12 weeks of surgery and in 84% cases (n = 42) by 16 weeks in this study [Table 7]. 80% of the patients achieved radiological union by 20 weeks [Table 8] and the most common pattern fracture pattern being 42A [Table 9].
Table 6: Time of full weight bearing

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Table 7: Clinical union time

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Table 8: Radiological union time

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Table 9: Relationship between radiological union and fracture pattern

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A total of 14 secondary procedures were performed with dynamisation being the most common followed by nail removal [Table 10].
Table 10: Secondary procedures performed

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Infection (superficial + deep) occurred in 10% patients in this study [Table 11]. This is comparatively higher than other studies by Klemm KW, Börner M [5] (0.9%), Bone LB, Johnson KD [6] (4.4%), and Court-Brown CM, McBirnie J [7] (1.8%).
Table 11: Complications in study population

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Delayed union in eight cases (16%), malunion in seven cases (14%), and nonunion in two cases (4%) were found in this study. Incidence of delayed union was 12.5%, non-union 7% and mal-union 5% according to the study by Blachut PA, O'Brien PJ, Meek RN and Broekhuyse HM.[8] Wiss DA, Stetson WB [9] reported 11% delayed union, 2% nonunion, and 5% malunion in their study of 101 cases. Hence, the incidence of delayed union and malunion is higher in the present study.

Other complications in the present study were distraction at fracture site (2%, n = 1), knee stiffness (8%, n = 4), ankle stiffness (2%, n = 1), hardware prominence (8%, n = 4), and implant failure (8%, n = 4). Anterior knee pain was the most common complication found in 20% patients (n = 10) [Table 11]. This is in accordance with the findings of the studies by Toivanen et al.[10] and by Váistö.[11] These complications were present in 16 patients (32%) with 13 patients (26%) having more than one complication.

In this study, final outcome was measured using Johner and Wruhs' criteria with modification, and excellent result was achieved in 48% patients, good in 34% patients, fair in 12% patients, and poor in 6% patients [Table 12] and Annexure 1]. Thus, excellent-good results are found in 82 % patients and fair-poor results in 18% patients. In similar studies, Klemm KW, Börner M [5] reported 94.3% excellent-to-good and 5.7% fair-poor result. Olerud S, Karlström G [12] reported 91% excellent-good and 9% fair-poor result. Hence, the final outcome in this study is less favorable than the other two studies mentioned.
Table 12: Final outcome according to Johner and Wruhs' Criteria[3] with modification

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  Conclusion Top


To conclude, closed interlocking nail for closed tibial diaphyseal fractures of tibia is not a 'full-proof' technique. It leads to high rates of union with early return of function. However, like any method it has its own complications mainly anterior knee pain, infection, need for secondary procedures, etc. Complication rates in present study are higher compared to western literature. So, advantages over conservative methods and its complications, both should be explained and an informed consent taken before 'interlocking' a closed tibial diaphyseal fracture.

Limitations of the study

This is single centre, unrandomized, retrospective, observational study of small sample size of 50 only. Recall bias could not be excluded. Little information was available regarding per-operative complications. Whether reamed nail or an unreamed nail was used was not known in most cases. Level of fibula fracture and its fixation was not taken into account.

It requires a large, multicentre, randomised, prospective study with a predetermined study design to validate the different aspects of this established method.

Acknowledgment

We would like to thank Prof. (Dr.) Chinmay De, Professor and the Head of the Department of Orthopaedics. His valuable advice and supervision were instrumental for completion of this project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Höntzsch D, Weller S, Perren SM. A new general orthopaedic universal intramedullary nail for the tibia: Clinical development and experiences. Aktuelle Traumatol 1989;19:225-37.  Back to cited text no. 1
    
2.
Jain V, Aggarwal A, Mehtani A, Jain P, Garg V, Dhaon BK. Primary unreamed intramedullary locked nailing in open fracture of tibia. Indian J Orthop 2005;39:30-2.  Back to cited text no. 2
  [Full text]  
3.
Johner R, Wruhs O. Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop Relat Res 1983;178:7-25.  Back to cited text no. 3
    
4.
Maruthi CV, Shivanna S. Tibial shaft fractures managed by intramedullary interlocking nail: A prospective study. J Evol Med Dent Sci 2015;4:12530-6.  Back to cited text no. 4
    
5.
Klemm KW, Börner M. Interlocking nailing of complex fractures of femur and tibia. Clin Orthop Relat Res 1986;212:89-100.  Back to cited text no. 5
    
6.
Bone LB, Johnson KD. Treatment of tibial fractures by reaming and intramedullary nailing. J Bone Joint Surg Am 1986;68:877-87.  Back to cited text no. 6
    
7.
Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg Br 1995;77:417-21.  Back to cited text no. 7
    
8.
Blachut PA, O'Brien PJ, Meek RN, Broekhuyse HM. Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am 1997;79:640-6.  Back to cited text no. 8
    
9.
Wiss DA, Stetson WB. Unstable fractures of the tibia treated with a reamed intramedullary interlocking nail. Clin Orthop Relat Res 1995;315:56-63.  Back to cited text no. 9
    
10.
Toivanen JA, Väistö O, Kannus P, Latvala K, Honkonen SE, Järvinen MJ, et al. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft. A prospective, randomized study comparing two different nail-insertion techniques. J Bone Joint Surg Am 2002;84-A: 580-5.  Back to cited text no. 10
    
11.
Väistö O, Toivanen J, Kannus P, Järvinen M. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: An eight-year follow-up of a prospective, randomized study comparing two different nail-insertion techniques. J Trauma 2008;64:1511-6.  Back to cited text no. 11
    
12.
Olerud S, Karlström G. Tibial fractures treated by AO compression osteosynthesis. Experiences from a five year material. Acta Orthop Scand Suppl 1972;140:1-104.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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