Session I - Tibia Fractures

Reamed or Unreamed Intramedullary Nailing for Closed and Open Grade I Tibial Shaft Fractures?

Christophe Sadowski, MD, Albert Schopfer, MD, Bertrand Le Coultre, MD, Robin Peter, MD

Clinique d'Orthopédie et de Chirurgie, Geneva University Hospital, Geneva, Switzerland

Purpose: Unreamed tibial nailing (UTN) has been shown to be successful in the treatment of open tibial fractures grade II to IIIB. The purpose of this study was to evaluate the results of UTN used for closed and open grade I fractures, and to compare these results with a similar group of patients treated previously with the universal reamed AO/ASIF tibial nail (RN).

Methods: Since first introduced in March, 1992, the AO/ASIF UTN was used in 85 cases until December, 1994. Initially used for open fractures, indications were progressively extended to most of tibial fractures by some of the surgeons at our institution. The study group is formed by 47 patients treated with UTN, who were prospectively followed until union. As open grade I fractures are generally treated as closed fractures, both types were included. Exclusion criteria were polytraumatism or associated injuries interfering with rehabilitation, pathological fractures and combined fixations. The control group consisted in the first series of 52 patients treated by RN meeting the same inclusion criteria. Both groups were comparable in terms of age, type of trauma, distribution of AO 42 A, B and C classified fractures, and number of open and closed fractures. We analyzed the mean time to radiological and clinical union, the amount and type of complications, and the need for further surgery to achieve union. Alternate Welch t-test and Fisher's exact test were used for statistical analysis.

Results: The mean time to union for patients treated with UTN was 22.8 weeks which was significantly more than 16.2 weeks for the RN group (p<0.01). Total number of complications, such as delayed (>6 months) and non-unions (>10 months), and screw breakage, as well as the total number of reoperations (exchange nailing, bone graft, and dynamization), were significantly higher in the UTN group (p<0.0001). If we do not consider screw breakage (seen only in the UTN group), the p value for the difference in the number of complications was 0.053 which is not significant, but shows a trend in favor of the reamed nail. Finally, the number of patients united at 6 months without any further surgery was 23/47 for the UTN group, which was less than 41/52 for the RN group (p<0.05).

A compartment syndrome occurred in 3 patients of the unreamed group and in 5 of the reamed group. There was one malunion in each group needing derotation osteotomies. There were no cases of infection.

Discussion: These results show clearly that closed and open grade I diaphyseal fractures of the tibia treated by unreamed nailing have a longer time to union, a higher rate of complications and a greater need for further surgery, when compared to a similar group of patients treated by reamed nailing. Despite relatively small groups and the non randomized design of the study, we feel that reaming of such fractures is probably safer for these patients. We have changed our practice accordingly, except when there is a specific indication for unreamed nailing such as a narrow medullary cavity or a segmental fracture.

Conclusion: Although unreamed nails are certainly useful for treatment of severe open fractures, we believe that closed and open grade I tibial fractures are best treated by reamed nailing. As others, we think that reaming may promote bone union.