The purpose of this study was to evaluate the role of locked intramedullary nailing without reaming for the treatment of open tibial and femoral shaft fractures that has recently been widely used all over the world, and recently evaluated. Seventy open femoral and tibial shaft fractures were treated by meticulous wound excision and early inter-locking nailing without reaming between 1996 and 1999 in our department. The average follow-up of the patients was 20.2 (12–36) months. Thirty-six were fractures of the tibia, and 34 of the femur. Ten (14.3%) were classified as Grade I., 32 (45.7%) as Grade II, and 28 (40%) as grade III according to Gustilo-Anderson. Most of the fractures were the result of high-energy trauma. In patients fixed with locked intramedullary nails due to no immobilisation, rehabilitation began just after the operation. Hip, knee and ankle functions were regained rapidly. All fractures were united in an average of 17.1 (10.1–36.6) weeks. There were six (8.6%) delayed unions and four superficial infections (5.7%). One patient developed deep infection (1.4%) and required further surgical treatment. Locking screws broke in one tibia (1.4%) and two femurs (2.8%), but the breakage did not result in loss of reduction. Although there was no nail breakage observed, two (2.9%) had between eight and twelve degrees external rotation, four (8.5%) shortening of 1.1 to 2.5 cm., and three (4.3%) valgus seven to ten degrees. Of the seventy fractures, 52 (74.2%) were classified according to Folleras as excellent, 8 (11.4%) as good, 6 (8.5%) as fair and 4 (5.7%) as poor. Early unreamed intramedullary interlocking nailing is a very effective and safe treatment method for open tibial and femoral shaft fractures.
We designed a prospective randomised trial to compare traditional conservative management with reaming, closed intramedullary nailing. Our aims were to compare early functional and the rehabilitation period between and of the two groups. The trial had strict criteria for entry: Group A) All patients were skeletally mature, Group B) All fractures were at least 50% displaced or angulated at least 10° in any direction, Group C) All patients had a displaced fracture of the tibial shaft more than 5 cm away from either knee or ankle and with no other significant injury, Group D) Only grade I compound fractures were admitted; grade II and III compound fractures were excluded. Group A was treated by manipulation of the fracture and the application of a long-leg plaster cast. Group B had closed intramedullary nailing of the fracture, with either dynamic or static locking as indicated. A total of 79 patients entered the trial: 37 in Group A and 42 in Group B. The criteria for fracture union was pain-free, unaided walking. There were two cases of non-union in Group A and none in Group B. Mean time to union was significantly shorter in Group B, as was the mean delay before return to work. There was significantly more angular deformity and shortening in Group A. Two patients in Group B had been nailed in significant external rotation (8 degrees). Movement at the knee, ankle and hindfoot was regained in the final control. Group B spent longer in hospital than group A. Group A had no cases of infection or wound problems. There was failure of conservative treatment in five of the 37 patients. These patients required late operation. Group B had one case of deep infection. In one case the distal locking screw was broken but no problem was encountered during follow-up. Autogenous bone grafting was performed in one case with non-union. We have concluded that displaced fractures of the tibial shaft are better and more efficiently treated by closed intramedullary nailing. This method has an acceptable complication rate when compared with conservative treatment.
We designed a prospective randomised trial to compare traditional conservative management with reaming, closed intramedullary nailing. Our aims were to compare early functional and the rehabilitation period between and of the two groups. The trial had strict criteria for entry: Group A) All patients were skeletally mature, Group B) All fractures were at least 50% displaced or angulated at least 10° in any direction, Group C) All patients had a displaced fracture of the tibial shaft more than 5 cm away from either knee or ankle and with no other significant injury, Group D) Only grade I compound fractures were admitted; grade II and III compound fractures were excluded. Group A was treated by manipulation of the fracture and the application of a long-leg plaster cast. Group B had closed intramedullary nailing of the fracture, with either dynamic or static locking as indicated. A total of 79 patients entered the trial: 37 in Group A and 42 in Group B. The criteria for fracture union was pain-free, unaided walking. There were two cases of non-union in Group A and none in Group B. Mean time to union was significantly shorter in Group B, as was the mean delay before return to work. There was significantly more angular deformity and shortening in Group A. Two patients in Group B had been nailed in significant external rotation (8 degrees). Movement at the knee, ankle and hindfoot was regained in the final control. Group B spent longer in hospital than group A. Group A had no cases of infection or wound problems. There was failure of conservative treatment in five of the 37 patients. These patients required late operation. Group B had one case of deep infection. In one case the distal locking screw was broken but no problem was encountered during follow-up. Autogenous bone grafting was performed in one case with non-union. We have concluded that displaced fractures of the tibial shaft are better and more efficiently treated by closed intramedullary nailing. This method has an acceptable complication rate when compared with conservative treatment.
