Session I - Tibia Fractures

Surgeon Randomized, Prospective Study Comparing Reamed versus Unreamed Intramedullary Nailing for the Treatment of Unstable Closed and Open Tibial Diaphyseal Fractures

Christopher G. Finkemeier, MD, Richard F. Kyle, MD, Andrew H. Schmidt, MD, David C. Templeman, MD, Thomas F. Varecka, MD

Hennepin County Medical Center, Minneapolis, Minnesota, USA

Purpose: To determine if there is a difference in healing or complications in open and closed tibia fractures treated with reamed or unreamed intramedullary nailing.

Significance: Unreamed, small diameter nails have become the treatment of choice for most open tibia fractures, but have been shown to have a high rate of hardware breakage and frequently require secondary procedures to obtain union. Reaming may offer advantages for fracture healing due to the use of larger implants and increased stability, but may cause higher rates of infection and compartment syndrome. Comparative data from well-designed studies to aid the clinician in choosing between these two techniques is lacking.

Conclusion: Our data supports the use of reamed nailing in closed tibia fractures due to earlier time to union without increased complications. In addition, reaming does not increase the risk of complications in grade I-IIIA open tibia fractures.

Methods: All closed and open (Gustillo types I, II and IIIA) tibia fractures treated with intramedullary nailing from November 1, 1994 to June 30, 1997 were studied prospectively. Three surgeons inserted all rods with reaming and three others inserted nails without reaming depending on who was the attending surgeon at the time of the nailing. Patients with narrow medullary canals (<8 mm) received reamed nails regardless of surgeon. Nail brand, the need for interlocking, post operative treatment and the need for secondary procedures (exchange nailing, bone grafting, dynamization) was left to the treating surgeon's preference.

Results: There were 94 total fractures in 90 patients. Fifty fractures (24 closed and 26 open) were unreamed and 44 fractures (25 closed and 19 open) were reamed. In open fractures, there was no significant difference in union rate at four, six or 12 months. There was no significant difference in the rates of infection, compartment syndrome or secondary procedures to obtain union between the reamed and unreamed groups. In closed fractures, reaming showed a significantly higher union rate at four months (p=.040), but not at six or twelve months. There was no significant difference in the rates of infection or compartment syndrome between the reamed and unreamed groups in closed fractures. For the entire series (both open and closed fractures), there were nine distal interlocking screw failures in six patients treated with unreamed nails and none in patients treated with reamed nails. This was a significant difference (p = 0.018). All screw failures occurred in distal one-third fractures and all but one failure occurred with either a spiral (42-Al) or oblique (42-A2) fracture configuration. Only one fracture had an unacceptable loss of alignment (neutral to 7 degrees of varus) as a result of a broken screw. The remaining fractures associated with broken locking screws healed uneventfully.

Discussion and Conclusion: In this study, reaming of open and closed fractures is associated with earlier union without any increased risk in infection or compartment syndrome. Although reaming of open fractures did not offer any significant advantage in time to union, there was no increased risk of infection or compartment syndrome. More secondary procedures were required to obtain union when small diameter, unreamed nails were used; this was most pronounced in closed fractures. These differences did not reach statistical significance with our small number of patients. There is a higher rate of interlocking bolt failure in small diameter rods inserted without reaming. This data does not support the current philosophy that unreamed rods are safer compared to reamed rods in either closed or open fractures. On the contrary, this data suggests that reaming is advantageous for fracture union in closed fractures, and may be safely performed in open fractures when the benefits of a larger nail and/or interlocking screws are desired. Reamed tibial nailing should be considered an appropriate treatment for all closed fractures and for grade I - IIIA open fractures.