Session VII - Tibia

Immediate Unreamed Nailing of Open Tibia Fractures: A Prospective Study

Paul Tornetta, III, MD; Timothy McConnell, MD, Boston Medical Center, Boston MA

Introduction: Success in the treatment of open tibia fractures is based on successful treatment of the soft tissue injury. Current protocols include emergent and aggressive debridement and stabilization followed by repeat debridements, early coverage, and delayed bony reconstruction. The purpose of this study is to review a prospective and consecutive series of open tibia fractures initially stabilized using an unreamed nail and to examine the effect of protocol driven management.

Methods: A consecutive series of 161 patients 16 to 83 years of age with grade I-IIIb open tibia fractures were entered into a prospective trial using unreamed, statically locked, titanium nails for immediate stabilization of their open tibia fractures. The Gustilo grading of the fractures was 37 (I), 62 (II), 43 (IIIa), and 19 (IIIb-requiring flap coverage). Sixty-two patients had associated injuries including 12 compartment syndromes. The standard protocol included emergent incision and drainage with immediate unreamed nailing, repeat incision and drainage until clean, delayed closure of flap within 14 days, and partial weightbearing at 8 to 12 weeks. Full weight bearing was permitted when there were signs of callus formation. Union was defined as bridging callus on 2 radiographic views, lack of tenderness at the fracture site, and unassisted weightbearing. Due to the difficulty in defining an exact date, time to union is reported as <6 months, 6-9 months, or >9 months. All data were collected prospectively.

Results: Three patients died from their injuries, 10 were lost to follow-up, and 5 dropped out of the protocol due to errors, leaving 143 fractures which were followed to union. Seventy-six fractures united in <6 months, 35 between 6 and 9 months, and 32 in >9 months. Twenty-five additional procedures were needed to obtain union in 16 of the delayed unions (12 exchanges, 4 bone grafts, 9 dynamizations). Six of the patients had exchange nailing after failure of dynamization. The other 16 patients with delayed union healed without secondary intervention. The 32 delayed unions were grades I (1), II (13), and III (18). For the entire series, complications included 3 cellulitis, 1 superficial infection, 4 deep infection (1 grade I, 3 grade II), 3 loose screws, 2 broken screws, 5 malunions > 5°, and 30 decreased ankle motion. Twenty-nine patients had complaints of minor knee pain, and 30 had occasional fracture site pain after activity despite clinical and radiographic union. Twelve patients considered themselves completely disabled (1 grade I, 5 grade II, 5 grade III). There were no amputations and no nonunions. The infections were treated with incision and drainage, then hardware removal after union of the fracture, and none are currently draining. One infection required 2 exchange nails. The overall screw failure rate was 0.5%, and there were no nail breakages. One 8-mm nail bent after a noncompliant patient with a segmental bone defect had been walking unrestricted for 8 months. Five patients did not get treated by the standard protocol; 3 were grade 3B but did not have adequate coverage by 14 days, and 2 were grade 2 injuries that did not have a second debridement. Four of these 5 patients had a complication.

Discussion: The results of this series confirm that the primary goal in the treatment of open tibia fractures is careful soft tissue management. Further, it justifies protocol driven management to avoid complications, because 4/5 patients who fell out of the protocol due to management errors had complications. The infection rate for the patients who were treated by protocol was 2.3%. The hardware failure rate is lower than in previously reported series and is most likely attributable to attempts to obtain cortical contact and avoid fracture gap in addition to the increased material strength of titanium implants. Overall satisfaction was good, but approximately one-third of the patients had some complaints of pain well after union.

Conclusion: Complications and outcomes after open tibia fractures are related to the soft tissue injury. Based on this series, the use of immediate unreamed tibial nailing appears to be safe and effective with minimal hardware failure. Despite a high union rate, one-third of patients still have some complaints after union.