SECONDARY NAILING AFTER EXTERNAL FIXATION OF TIBIAL FRACTURES: 59 CASES

Abstract

Purpose of the study: We report our experience with 59 cases of secondary nailing after external fixation of tibial fractures.

Material and methods: Between 1988 and 2002, 59 tibial fractures (58 patients) were treated initially by external fixation then by secondary nailing. The AO classification was: A (n=28), B (n=20), C (n=11). The Gustilo classification was: closed (n=28), grade 1 (n=18), grade 2 (n=10), grade 3A (n=1), grade 3C (n=2). Tibiotibial or tibio-calcaneal external fixation was used initially for these lower diaphysometaphyseal fractures. The reason for using external fixation was: soft tissue damage (n=38), complex fracture (n=14), associated injuries (n=7). Associated plastic surgery procedures were: medial gastrocnemius flap (n=1), skin graft (n=3). Secondary nailing was undertaken early in 41 cases at about the sixth week because of improvement in the local or general status. For seven cases, the secondary nailing was performed at about four weeks after the multiple-fragment fracture had partially consolidated. There were three infectious complications after nailing (abscess on screw, fistula, pandiaphysistis) in patients whose initial samples of the reaming material were bacteriologically negative. Bone healing was achieved after nailing in 56 cases. Dynamizing the nail was sufficient to achieve healing in one case. Two cases of septic non-union were nailed again and finally healed. The case of pandiaphysitis was treated by removing the nail then a new external fixation which was successful in achieving bone healing.

Results: The results of the secondary centromedullary nailing were satisfactory. Several operations were necessary however (removal of the fixator, nailing, dynaiztion, material removal) with considerable risk of infection. This two-stge method enables treatment of difficult situations rapidly (external fixation) and early (four weeks) revision to allow «programmed» treatment in safer conditions. This secondary nailing can also be used as a treatment in the event of late healing after initial external fixation. Contraindications are pin tract osteitis and serious local infection during the external fixation phase.