Saudi Journal of Sports Medicine

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


Aranyak Sarkar, Mrinal Kanti Ray, Biplab Chatterjee, Soumyadeep Duttaroy, Sanjid Islam, Chinmay De 
 Department of Orthopedics, Burdwan Medical College, Bardhaman, West Bengal, India

Correspondence Address:
Soumyadeep Duttaroy
Burdwan Medical College, Room No-11, J R Hostel, Bardhaman - 713 104, West Bengal
India

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.



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;18:119-123


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 2020 Feb 25 ];18:119-123
Available from: http://www.sjosm.org/text.asp?2018/18/3/119/270319


Full Text

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 Introduction



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



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

Subjective parameters

Resumption of activities of daily livingPain-free movement and walkingSquatting and sitting cross-legged

Objective parameters

Clinical

Weight-bearing time (partial/complete)Clinical union timeRange of motion of knee and ankleLimb length discrepancyNeurovascular damageInfectionNeed for second surgery

DynamizationExchange nailingBone graftingORIF with plate and bone grafting

Radiological

Radiological unionVarus/valgusProcurvatum/recurvatumRotational malalignmentImplant failure.

Study technique

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



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}{Table 2}{Table 3}{Table 4}

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}

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}{Table 7}{Table 8}{Table 9}

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

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}

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}

 Conclusion



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

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