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Early unreamed intramedullary nailing without a safety interval and simultaneous flap coverage following external fixation in type IIIB open tibial fractures: A report of four successful cases
Injury, Int. J. Care Injured (2006) 37, 289—294
www.elsevier.com/locate/injury
Early unreamed intramedullary nailing without a safety interval and simultaneous flap coverage following external fixation in type IIIB open tibial fractures: A report of four successful cases Masaki Ueno a, Kazuhiko Yokoyama c,*, Koushin Nakamura a, Masataka Uchino a, Takashi Suzuki b, Moritoshi Itoman a a
Department of Orthopaedic Surgery, School of Medicine, Kitasato University, 1-15-1 Kitasato, Sagamihara, Kanagawa 228-8555, Japan b Department of Emergency and Critical Care Medicine, School of Medicine, Kitasato University, 1-15-1 Kitasato, Sagamihara, Kanagawa 228-8555, Japan c Department of Orthopaedic Surgery, Machida Municipal Hospital, 2-15-41 Asahi-Machi, Machida, Tokyo 194-0023, Japan Accepted 24 August 2005
KEYWORDS Type IIIB open tibia fractures; Unreamed intramedullary nailing; External fixation; No safety interval; Early flap coverage
Summary The conversion method from external fixation (EF) to intramedullary nailing (IMN) for open tibia fractures, especially to Gustilo type IIIB open tibia fractures, have potentially high risk of infections. We document a report of a more progressive approach in four consecutive cases of type IIIB open tibial fractures successfully managed with early unreamed IMN without a safety interval and simultaneous flap coverage following EF. The mean patients age at the time of injury was 43.8 years (range 23—64 years), and three patients were male. The timing from EF to IMN without safety interval combined with well-vascularised flap (free latissimus dorsi flaps in two patients and pedicled soleus flaps in two patients) ranged 48 to 72 hours. Average time to union was 14 months (range 9—21 months). There was one nonunion patient whose fracture healing was gained by reamed IMN without bone grafting. However, there were no infections. The functions in all patients were satisfactory. This early unreamed IMN without a safety interval and with simultaneous flap coverage following EF is a useful and effective option for treating type IIIB open tibial fractures. # 2005 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +81 42 722 2230; fax: +81 42 720 5680. E-mail address: [email protected] (K. Yokoyama). 0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.08.018
290
Introduction Several authors have reported that secondary intramedullary nailing (IMN) after external fixation (EF) in tibial fractures carries a risk of intramedullary infection.6,7 Moreover, determining a protocol for safe delayed IMN after initial EF in severe open tibial fractures is thought to be difficult. We previously reported three successful cases of Gustilo type IIIB tibial fractures treated with a defined protocol of aggressive debridement, initial stabilisation with an external fixator and early flap coverage, followed by unreamed IMN after an average of 10 days.14 We now document a more aggressive approach in four consecutive cases of type IIIB open tibial fractures, which were successfully managed with early unreamed IMN and simultaneous flap coverage without a safety interval following EF.
General treatment principle for IIIB tibial fractures Debridement and external fixation are performed within 6 h of injury. Subsequent debridement, coverage by a well vascularised flap (free or pedicled), removal of the external fixator, and insertion of an
M. Ueno et al. unreamed IMN with an AO solid tibial nail are performed simultaneously 48—72 h after trauma, provided no bacteria are found immediately before the second operation in smears from the open wound and the entire pin-site area. Range-of-motion exercise and partial weight bearing are started a few days after the second operation. The typical hospital stay is 3—4 weeks.
Case reports Case 1 A 64-year-old female motorcyclist injured her lower left leg in a traffic accident. Immediately after the accident, she was transferred to our trauma unit. The skin of her leg was severely lacerated at the mid-portion and a fractured tibia was exposed with periosteal stripping (Fig. 1A). The initial radiograph showed mid-shaft tibio—fibular fractures. The open tibial fracture was initially stabilised with a Hoffmann external fixator after primary debridement within 6 h (Fig. 1C). On day 2, second look debridement, coverage by a free latissimus dorsi flap (Fig. 1B), removal of the external fixator, and unreamed IMN (Fig. 1D) were performed simultaneously.
Figure 1 Case 1: A 64-year-old woman with a type IIIB tibia fracture. (A) Gross appearance of the wound at initial debridement. The tibial fracture with associated periosteal stripping is clearly exposed in the wound. (B) Free latissimus dorsi flap surgery. (C) Radiograph of the tibia stabilised by a Hoffmann external fixator. (D) Unreamed IMN was performed at the same time as flap surgery on day 2. (E) Radiograph of the fracture healed after reamed IMN (21 months after injury).
Nailing following external fixation for tibial fractures
291
Figure 2 Case 2: A 23-year-old man with a type IIIB tibial fracture and an associated facial fracture. (A) Gross appearance of the wound at the time of admission. The soft tissue is severely damaged at the mid-portion of the leg. (B) Segmental fracture stabilised with a Hoffmann external fixator on day 0. (C) Unreamed IMN performed along with flap surgery on day 2. (D) Radiograph taken after removal of the tibial nail. Bony healing is complete.
Although there was no evidence of deep infection, radiographic union was not confirmed 10 months after the injury; hypertrophic nonunion was diagnosed and reamed IMN without bone grafting was performed 12 months after the injury. Fracture healing was finally confirmed 21 months after the injury (Fig. 1E). The patient regained acceptable function and was satisfied with her status 3 years after injury.
malleolus were performed simultaneously (Fig. 2C). There were no subsequent signs of infection, consolidated union was confirmed radiographically 1 year after injury, and implants were removed 2 years and 7 months after placement (Fig. 2D). The patient had returned to nearly full activity at the final follow-up.
Case 2
A 28-year-old male motorcyclist injured his lower leg in a traffic accident. He was directly transferred to our trauma unit from the accident scene. The initial radiographs showed a tibio—fibular fracture at a midportion; an associated soft-tissue injury was classified as type IIIB. Initial bony stabilisation was performed with a Hoffmann external frame after timely wound debridement (Fig. 3A). At 48 h after the injury, second look debridement, coverage with a pedicled soleus flap (Fig. 3B), removal of the external fixator, and unreamed IMN were performed simultaneously. Bony healing was confirmed 14 months after injury, with no evidence of infection or malunion.
A 23-year-old male truck driver injured his lower leg in a traffic accident. He was directly transferred from the accident scene to our trauma centre. The skin of his leg was severely lacerated at the midportion and a fractured tibia was exposed (Fig. 2A). The initial radiographs showed segmental fractures of the tibial and fibular shafts and a fracture of the medial malleolus. The patient also had a facial fracture from the accident, and his Injury Severity Score (ISS)1 was 13. The open tibial fracture was initially stabilised with a Hoffmann external fixator and the open wound was partially closed following timely debridement (Fig. 2B). On day 2, second look debridement, coverage with a pedicled soleus flap, removal of the external fixator, and unreamed IMN combined with cannulated screwing of the medial
Case 3
Case 4 A 60-year-old male car driver injured his lower leg in a traffic accident. He was directly transferred to our
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M. Ueno et al.
Figure 3 Case 3: A 28-year-old man with a type IIIB tibial fracture. (A) Gross appearance of the wound after external fixation. (B) Pedicled soleus flap elevation.
trauma unit from the accident scene. The initial radiographs showed a distal tibio—fibular fracture; an associated soft-tissue injury was classified as type IIIB (Fig. 4A). Initial bony stabilisation was performed with a Hoffmann external frame after timely wound debridement. At 72 h after the injury, second look debridement (including 1.5 cm of bone shortening), coverage with a free latissimus dorsi flap (Fig. 4B), removal of the external fixator, and unreamed IMN were performed simultaneously. Bony healing was confirmed 9 months after the injury (Fig. 4C) with no evidence of infection or malunion. However, flap reduction was performed 16 months after the injury because the patient was concerned with his discomfort putting on shoes. The four cases are summarised in Table 1.
Discussion Several authors have advised against secondary nailing of open fractures after primary treatment with EF.3,4 In two previous reports6,7, infection rates were reported to range from 25% to 44% with this treatment regimen for open tibial fractures. Mauer
et al.6 demonstrated that there was a significant increase in the risk of developing subsequent deep infection when nailing was performed after evidence of pin track infection. Accordingly, they stressed that pin track infection was a contraindication to secondary nailing. We supported this perspective in our previous papers.13,14 Johnson et al.,5 Blachut et al.,2 and Wu and Shih12 reported a low infection rate when EF is replaced with delayed IMN. Riemer and Butterfield10 reported a comparison study between reamed and unreamed solid nailing of the tibia after EF and concluded that unreamed IMN was efficacious and might be preferable to reamed IMN. From the findings of the above reports, four key points should be followed when performing delayed IMN to replace EF: (1) a short period of EF, (2) early unreamed IMN, (3) a few weeks’ safety interval from removal of EF to IMN, and (4) early vascularised flap coverage (within 1 week). On the basis of the above studies, we tried a modified regimen: (1) acute flap coverage within 4 days, (2) short duration of external fixation, (3) early unreamed IMN, (4) aggressive initial or second look debridement of the open wound and sequential debridement of the screw hole at the pin site in the
Nailing following external fixation for tibial fractures
293
Figure 4 Case 4: A 60-year-old man with a type IIIB tibial fracture. (A) Gross appearance of the wound during initial debridement. The tibial fracture with associated periosteal stripping (at the distal portion) is clearly exposed in the wound. (B) Following free latissimus dorsi flap surgery. (C) Fracture healed 9 months after injury.
interval lengths. In the report of McGraw and Lim,7 the interval was about 3 weeks, but they found no correlation between treatment outcome and this interval. Mauer et al.6 recommended an interval of more than 3 weeks based on an experimental study in a canine model.9 On the other hand, in other studies,2,8,11 no increased risk of infection could be found when there was no interval at all and nailing was performed in the same procedure as the removal of external fixator. Siebenrock et al. reported that the existence of clinical signs of
removal of EF, and (5) a slightly longer waiting time from the removal of the EF to IMN until complete healing of the pin site. We previously reported three successful cases of type IIIB open tibia fracture healing on the basis of the above regimen.14 Waiting time from the removal of the EF to IMN in the above regimen is thought to be an impediment to minimising the treatment period. There is still debate about leaving an interval between the removal of EF and sequential nail implantation. Several authors6,7,12 have recommended different
Table 1 Data on four patients who underwent surgery Case 1 2 3 4
Sex/age (years)
ISS
F/64 M/23 M/28 M/60
9 13 9 9
Location Mid 1/3 Mid 1/3 Mid 1/3 Dist 1/3
Soft-tissue coverage (days after injury)
Duration interval Ex fix (days)
Free LD flap (2) Soleus flap (2) Soleus flap (2) Free LD flap (3)
2 2 2 3
ISS, Injury Severity Score;1 Ex fix, external fixation; LD, latissimus dorsi.
Ex fix-nail (days)
Deep infection
Time to union (months)
0 0 0 0
No No No No
21 12 14 9
294 infection around the pin track in the absence of a safety interval was related to deep infection in these sequential nailings.11 We accepted this clinical evidence and performed secondary one-stage nailing without a safety interval, combined with flap surgery after EF for very short period (48—72 h after trauma), in four cases of type IIIB open tibial fractures in which no bacteria were found in smears from the open wound and the entire pin-site area. There were no infections and no malunions, but one delayed union required reamed nailing (Case 1). This early unreamed IMN without a safety interval and with simultaneous flap coverage following EF is a useful and effective option for treating type IIIB open tibial fractures. In patients with severe multiple injuries (e.g., head, chest, and abdominal injuries) and unstable pelvic injury, however, the timing for soft-tissue coverage such as free flap surgery may be delayed and application of this regimen for these patients may be unreasonable. Moreover, clinical trials of more such cases, prospective trials, or a multi-centre study are needed to ascertain the effectiveness of this regimen.
References 1. Baker SP, O’Neill B, Haddon Jr W, Long WB. The injury severity score: a method of describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187—96. 2. Blachut PA, Meek RN, O’Brien PJ. External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. J Bone Joint Surg Am 1990;72-A:729—35.
M. Ueno et al. 3. Blick SS, Brumback RJ, Lakatos R, et al. Early prophylactic bone grafting of high-energy tibial fractures. Clin Orthop 1989;240:21—41. 4. Gustilo RB, Merkow RL, Templeman D. Current concepts review–—the management of open fractures. J Bone Joint Surg Am 1990;72-A:299—304. 5. Johnson EE, Simpson LA, Helfet DL. Delayed intramedullary nailing after failed external fixation of the tibia. Clin Orthop 1990;253:251—7. 6. Mauer D, Merkow RL, Gustilo RB. Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation. J Bone Joint Surg Am 1989;71-A:835— 8. 7. McGraw JM, Lim EVA. Treatment of open tibial-shaft fractures. External fixation and secondary intramedullary nailing. J Bone Joint Surg Am 1988;70-A:900—11. 8. Rennirt G, Seligson D. One stage secondary intramedullary nailing. Osteosynthese Int 1993;2:84—8. 9. Respet PJ, Kleinman PG, Meinhard BP. Pin tract infections: a canine model. J Orthop Res 1987;5:600—3. 10. Riemer BL, Butterfield SL. Comparison of reamed and nonreamed solid core nailing of the tibial diaphysis after external fixation: a preliminary report. J Orthop Trauma 1993;7:279— 85. 11. Siebenrock KA, Gerich T, Jakob RP. Sequential intramedullary nailing of open tibial shaft fractures after external fixation. Arch Orthop Trauma Surg 1997;116:32—6. 12. Wu CC, Shih CH. Complicated open fractures of the tibia treated by secondary interlocking nailing. J Trauma 1993;34:792—6. 13. Yokoyama K, Itoman M, Shindo M, Kai H. Contributing factors influencing type III open tibial fractures. J Trauma 1995;38:788—93. 14. Yokoyama K, Itoman M, Tanaka K, et al. Secondary undreamed intramedullary nailing following external fixation and acute flap coverage for type IIIb open tibia fractures: a report of three successful cases. J Orthop Surg 1998;6: 71—7.
www.elsevier.com/locate/injury
Early unreamed intramedullary nailing without a safety interval and simultaneous flap coverage following external fixation in type IIIB open tibial fractures: A report of four successful cases Masaki Ueno a, Kazuhiko Yokoyama c,*, Koushin Nakamura a, Masataka Uchino a, Takashi Suzuki b, Moritoshi Itoman a a
Department of Orthopaedic Surgery, School of Medicine, Kitasato University, 1-15-1 Kitasato, Sagamihara, Kanagawa 228-8555, Japan b Department of Emergency and Critical Care Medicine, School of Medicine, Kitasato University, 1-15-1 Kitasato, Sagamihara, Kanagawa 228-8555, Japan c Department of Orthopaedic Surgery, Machida Municipal Hospital, 2-15-41 Asahi-Machi, Machida, Tokyo 194-0023, Japan Accepted 24 August 2005
KEYWORDS Type IIIB open tibia fractures; Unreamed intramedullary nailing; External fixation; No safety interval; Early flap coverage
Summary The conversion method from external fixation (EF) to intramedullary nailing (IMN) for open tibia fractures, especially to Gustilo type IIIB open tibia fractures, have potentially high risk of infections. We document a report of a more progressive approach in four consecutive cases of type IIIB open tibial fractures successfully managed with early unreamed IMN without a safety interval and simultaneous flap coverage following EF. The mean patients age at the time of injury was 43.8 years (range 23—64 years), and three patients were male. The timing from EF to IMN without safety interval combined with well-vascularised flap (free latissimus dorsi flaps in two patients and pedicled soleus flaps in two patients) ranged 48 to 72 hours. Average time to union was 14 months (range 9—21 months). There was one nonunion patient whose fracture healing was gained by reamed IMN without bone grafting. However, there were no infections. The functions in all patients were satisfactory. This early unreamed IMN without a safety interval and with simultaneous flap coverage following EF is a useful and effective option for treating type IIIB open tibial fractures. # 2005 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +81 42 722 2230; fax: +81 42 720 5680. E-mail address: [email protected] (K. Yokoyama). 0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.08.018
290
Introduction Several authors have reported that secondary intramedullary nailing (IMN) after external fixation (EF) in tibial fractures carries a risk of intramedullary infection.6,7 Moreover, determining a protocol for safe delayed IMN after initial EF in severe open tibial fractures is thought to be difficult. We previously reported three successful cases of Gustilo type IIIB tibial fractures treated with a defined protocol of aggressive debridement, initial stabilisation with an external fixator and early flap coverage, followed by unreamed IMN after an average of 10 days.14 We now document a more aggressive approach in four consecutive cases of type IIIB open tibial fractures, which were successfully managed with early unreamed IMN and simultaneous flap coverage without a safety interval following EF.
General treatment principle for IIIB tibial fractures Debridement and external fixation are performed within 6 h of injury. Subsequent debridement, coverage by a well vascularised flap (free or pedicled), removal of the external fixator, and insertion of an
M. Ueno et al. unreamed IMN with an AO solid tibial nail are performed simultaneously 48—72 h after trauma, provided no bacteria are found immediately before the second operation in smears from the open wound and the entire pin-site area. Range-of-motion exercise and partial weight bearing are started a few days after the second operation. The typical hospital stay is 3—4 weeks.
Case reports Case 1 A 64-year-old female motorcyclist injured her lower left leg in a traffic accident. Immediately after the accident, she was transferred to our trauma unit. The skin of her leg was severely lacerated at the mid-portion and a fractured tibia was exposed with periosteal stripping (Fig. 1A). The initial radiograph showed mid-shaft tibio—fibular fractures. The open tibial fracture was initially stabilised with a Hoffmann external fixator after primary debridement within 6 h (Fig. 1C). On day 2, second look debridement, coverage by a free latissimus dorsi flap (Fig. 1B), removal of the external fixator, and unreamed IMN (Fig. 1D) were performed simultaneously.
Figure 1 Case 1: A 64-year-old woman with a type IIIB tibia fracture. (A) Gross appearance of the wound at initial debridement. The tibial fracture with associated periosteal stripping is clearly exposed in the wound. (B) Free latissimus dorsi flap surgery. (C) Radiograph of the tibia stabilised by a Hoffmann external fixator. (D) Unreamed IMN was performed at the same time as flap surgery on day 2. (E) Radiograph of the fracture healed after reamed IMN (21 months after injury).
Nailing following external fixation for tibial fractures
291
Figure 2 Case 2: A 23-year-old man with a type IIIB tibial fracture and an associated facial fracture. (A) Gross appearance of the wound at the time of admission. The soft tissue is severely damaged at the mid-portion of the leg. (B) Segmental fracture stabilised with a Hoffmann external fixator on day 0. (C) Unreamed IMN performed along with flap surgery on day 2. (D) Radiograph taken after removal of the tibial nail. Bony healing is complete.
Although there was no evidence of deep infection, radiographic union was not confirmed 10 months after the injury; hypertrophic nonunion was diagnosed and reamed IMN without bone grafting was performed 12 months after the injury. Fracture healing was finally confirmed 21 months after the injury (Fig. 1E). The patient regained acceptable function and was satisfied with her status 3 years after injury.
malleolus were performed simultaneously (Fig. 2C). There were no subsequent signs of infection, consolidated union was confirmed radiographically 1 year after injury, and implants were removed 2 years and 7 months after placement (Fig. 2D). The patient had returned to nearly full activity at the final follow-up.
Case 2
A 28-year-old male motorcyclist injured his lower leg in a traffic accident. He was directly transferred to our trauma unit from the accident scene. The initial radiographs showed a tibio—fibular fracture at a midportion; an associated soft-tissue injury was classified as type IIIB. Initial bony stabilisation was performed with a Hoffmann external frame after timely wound debridement (Fig. 3A). At 48 h after the injury, second look debridement, coverage with a pedicled soleus flap (Fig. 3B), removal of the external fixator, and unreamed IMN were performed simultaneously. Bony healing was confirmed 14 months after injury, with no evidence of infection or malunion.
A 23-year-old male truck driver injured his lower leg in a traffic accident. He was directly transferred from the accident scene to our trauma centre. The skin of his leg was severely lacerated at the midportion and a fractured tibia was exposed (Fig. 2A). The initial radiographs showed segmental fractures of the tibial and fibular shafts and a fracture of the medial malleolus. The patient also had a facial fracture from the accident, and his Injury Severity Score (ISS)1 was 13. The open tibial fracture was initially stabilised with a Hoffmann external fixator and the open wound was partially closed following timely debridement (Fig. 2B). On day 2, second look debridement, coverage with a pedicled soleus flap, removal of the external fixator, and unreamed IMN combined with cannulated screwing of the medial
Case 3
Case 4 A 60-year-old male car driver injured his lower leg in a traffic accident. He was directly transferred to our
292
M. Ueno et al.
Figure 3 Case 3: A 28-year-old man with a type IIIB tibial fracture. (A) Gross appearance of the wound after external fixation. (B) Pedicled soleus flap elevation.
trauma unit from the accident scene. The initial radiographs showed a distal tibio—fibular fracture; an associated soft-tissue injury was classified as type IIIB (Fig. 4A). Initial bony stabilisation was performed with a Hoffmann external frame after timely wound debridement. At 72 h after the injury, second look debridement (including 1.5 cm of bone shortening), coverage with a free latissimus dorsi flap (Fig. 4B), removal of the external fixator, and unreamed IMN were performed simultaneously. Bony healing was confirmed 9 months after the injury (Fig. 4C) with no evidence of infection or malunion. However, flap reduction was performed 16 months after the injury because the patient was concerned with his discomfort putting on shoes. The four cases are summarised in Table 1.
Discussion Several authors have advised against secondary nailing of open fractures after primary treatment with EF.3,4 In two previous reports6,7, infection rates were reported to range from 25% to 44% with this treatment regimen for open tibial fractures. Mauer
et al.6 demonstrated that there was a significant increase in the risk of developing subsequent deep infection when nailing was performed after evidence of pin track infection. Accordingly, they stressed that pin track infection was a contraindication to secondary nailing. We supported this perspective in our previous papers.13,14 Johnson et al.,5 Blachut et al.,2 and Wu and Shih12 reported a low infection rate when EF is replaced with delayed IMN. Riemer and Butterfield10 reported a comparison study between reamed and unreamed solid nailing of the tibia after EF and concluded that unreamed IMN was efficacious and might be preferable to reamed IMN. From the findings of the above reports, four key points should be followed when performing delayed IMN to replace EF: (1) a short period of EF, (2) early unreamed IMN, (3) a few weeks’ safety interval from removal of EF to IMN, and (4) early vascularised flap coverage (within 1 week). On the basis of the above studies, we tried a modified regimen: (1) acute flap coverage within 4 days, (2) short duration of external fixation, (3) early unreamed IMN, (4) aggressive initial or second look debridement of the open wound and sequential debridement of the screw hole at the pin site in the
Nailing following external fixation for tibial fractures
293
Figure 4 Case 4: A 60-year-old man with a type IIIB tibial fracture. (A) Gross appearance of the wound during initial debridement. The tibial fracture with associated periosteal stripping (at the distal portion) is clearly exposed in the wound. (B) Following free latissimus dorsi flap surgery. (C) Fracture healed 9 months after injury.
interval lengths. In the report of McGraw and Lim,7 the interval was about 3 weeks, but they found no correlation between treatment outcome and this interval. Mauer et al.6 recommended an interval of more than 3 weeks based on an experimental study in a canine model.9 On the other hand, in other studies,2,8,11 no increased risk of infection could be found when there was no interval at all and nailing was performed in the same procedure as the removal of external fixator. Siebenrock et al. reported that the existence of clinical signs of
removal of EF, and (5) a slightly longer waiting time from the removal of the EF to IMN until complete healing of the pin site. We previously reported three successful cases of type IIIB open tibia fracture healing on the basis of the above regimen.14 Waiting time from the removal of the EF to IMN in the above regimen is thought to be an impediment to minimising the treatment period. There is still debate about leaving an interval between the removal of EF and sequential nail implantation. Several authors6,7,12 have recommended different
Table 1 Data on four patients who underwent surgery Case 1 2 3 4
Sex/age (years)
ISS
F/64 M/23 M/28 M/60
9 13 9 9
Location Mid 1/3 Mid 1/3 Mid 1/3 Dist 1/3
Soft-tissue coverage (days after injury)
Duration interval Ex fix (days)
Free LD flap (2) Soleus flap (2) Soleus flap (2) Free LD flap (3)
2 2 2 3
ISS, Injury Severity Score;1 Ex fix, external fixation; LD, latissimus dorsi.
Ex fix-nail (days)
Deep infection
Time to union (months)
0 0 0 0
No No No No
21 12 14 9
294 infection around the pin track in the absence of a safety interval was related to deep infection in these sequential nailings.11 We accepted this clinical evidence and performed secondary one-stage nailing without a safety interval, combined with flap surgery after EF for very short period (48—72 h after trauma), in four cases of type IIIB open tibial fractures in which no bacteria were found in smears from the open wound and the entire pin-site area. There were no infections and no malunions, but one delayed union required reamed nailing (Case 1). This early unreamed IMN without a safety interval and with simultaneous flap coverage following EF is a useful and effective option for treating type IIIB open tibial fractures. In patients with severe multiple injuries (e.g., head, chest, and abdominal injuries) and unstable pelvic injury, however, the timing for soft-tissue coverage such as free flap surgery may be delayed and application of this regimen for these patients may be unreasonable. Moreover, clinical trials of more such cases, prospective trials, or a multi-centre study are needed to ascertain the effectiveness of this regimen.
References 1. Baker SP, O’Neill B, Haddon Jr W, Long WB. The injury severity score: a method of describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187—96. 2. Blachut PA, Meek RN, O’Brien PJ. External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. J Bone Joint Surg Am 1990;72-A:729—35.
M. Ueno et al. 3. Blick SS, Brumback RJ, Lakatos R, et al. Early prophylactic bone grafting of high-energy tibial fractures. Clin Orthop 1989;240:21—41. 4. Gustilo RB, Merkow RL, Templeman D. Current concepts review–—the management of open fractures. J Bone Joint Surg Am 1990;72-A:299—304. 5. Johnson EE, Simpson LA, Helfet DL. Delayed intramedullary nailing after failed external fixation of the tibia. Clin Orthop 1990;253:251—7. 6. Mauer D, Merkow RL, Gustilo RB. Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation. J Bone Joint Surg Am 1989;71-A:835— 8. 7. McGraw JM, Lim EVA. Treatment of open tibial-shaft fractures. External fixation and secondary intramedullary nailing. J Bone Joint Surg Am 1988;70-A:900—11. 8. Rennirt G, Seligson D. One stage secondary intramedullary nailing. Osteosynthese Int 1993;2:84—8. 9. Respet PJ, Kleinman PG, Meinhard BP. Pin tract infections: a canine model. J Orthop Res 1987;5:600—3. 10. Riemer BL, Butterfield SL. Comparison of reamed and nonreamed solid core nailing of the tibial diaphysis after external fixation: a preliminary report. J Orthop Trauma 1993;7:279— 85. 11. Siebenrock KA, Gerich T, Jakob RP. Sequential intramedullary nailing of open tibial shaft fractures after external fixation. Arch Orthop Trauma Surg 1997;116:32—6. 12. Wu CC, Shih CH. Complicated open fractures of the tibia treated by secondary interlocking nailing. J Trauma 1993;34:792—6. 13. Yokoyama K, Itoman M, Shindo M, Kai H. Contributing factors influencing type III open tibial fractures. J Trauma 1995;38:788—93. 14. Yokoyama K, Itoman M, Tanaka K, et al. Secondary undreamed intramedullary nailing following external fixation and acute flap coverage for type IIIb open tibia fractures: a report of three successful cases. J Orthop Surg 1998;6: 71—7.