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Intramedullary Fixation in Fractures of the Shaft of the Tibia
Intramedullary Fixation in Fractures of the Shaft of the Tibia From the Department of Orthopaedic Surgery, Western Reserve University School of Medicine and University Hospitals of Cleveland, Ohio
GEORGE E. SPENCER, JR., M.D. Assistant Professor of Orthopaedic Surgery
THE USE of intramedullary fixation for fractures of the shaft of the tibia still remains a somewhat controversial subject. Many surgeons and clinics are highly enthusiastic about this method of therapYj4. 11. 20 others condemn it vigorously and point out that the original users of intramedullary nailing for long bones, Kuntscher and Buehler, have abandoned the technique for fixation of fractures of the shaft of the tibia. 2 • I. The recent literature on this subject indicates that the method as described by Lottes 7 • 8 appears to be by far the most accepted and successful method of intramedullary nailing of the tibia. 3 • 4 In recent studies and reports regarding open reduction of the shaft of the tibia, most authors have indicated that the best method of internal fixation for tibial shaft fractures is the intramedullary nail. 9 • 17 We believe that this method is excellent when internal fixation becomes necessary in treating fractures of the shaft of the tibia. A closed reduction should be obtained and maintained if at all possible but, if this fails, the blind nailing method of Lottes is preferred in those fractures where internal fixation is indicated. Our experience has been confined to the use of the Lottes type nail for intramedullary fixation of the shaft of the tibia. INDICATIONS
The method can be used for any fracture of the shaft of the tibia from the junction of the upper and middle third to within 3 inches of the ankle joint. It functions most effectively and efficiently in fractures of the middle third of the shaft of the tibia. It is particularly helpful in segmental fractures because one of the fractures is almost always in this
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GEORGE
E.
SPENCER, JR.
Fig. 1. E.J., age 59, white female, closed pathological fracture from metastatic tumor of uterus. X-ray therapy was given. No cast was necessary. The patient died 6 months post nailing, never having achieved full weight bearing.
area. There appears to be no advantage to using this method in fractures of the upper third or the distal end of the tibia. One point must be qualified, however: There must be an adequate medullary canal. Paget's disease, fibrous dysplasia or any sclerotic lesion may obliterate the medullary canal. ADVANTAGES
The blind method of insertion should be adhered to as advocated by Lottes. If this is not done, many of the advantages of the method are lost. Blind insertion preserves the skin over the fracture site. This is most important because the skin is usually subject to necrosis and the circulation to the skin of the lower third of the leg is usually precarious. The method also preserves the skin as the best dressing over the fracture. The circulation to the cortex of the tibia is disturbed much less than if an open reduction is performed. It is important to preserve the periosteal circulation because intramedullary fixation compromises the endosteal blood supply, and the periosteal circulation must then contribute most of the circulation. As pointed out by Jackson and Macnab,5 the periosteal supply is very important in formation of the callus of a fracture of the shaft of the tibia. Early ambulation with weight bearing can be achieved more quickly and the stress factor, which is so important in the union of fractures, may be instituted earlier. The patient's leg is immobilized in a cast for an average of eight weeks, which is considerably shorter than if external fixation alone is used. It is thought that earlier union is obtained, but this point can be debated. From a clinical standpoint, union occurs earlier, for the patient can bear full weight out of his cast sooner and can perform in a more normal manner.
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The nail has a distinct advantage in segmental fractures, l for these are unstable and any other form of internal fixation requires considerable dissection of the soft parts. The method has proved to be of great advantage in pathological fractures because the entire shaft of the bone is used to stabilize the fracture; unless the entire bone is involved, this method offers the best means of internal fixation available (Fig. 1). It has proved to be a great help in fractures which require a cross-leg flap to gain soft tissue coverage and other similar procedures in which external fixation alone would not efficiently provide adequate stabilization of the fractured tibia. The method can be used in fresh fractures, compound fractures and delayed unions and nonunions. Because of the intramedullary position of the nail, there is less bulk and it is easier to place bone grafts about the fracture site. DISADVANTAGES
The blind method of internal fixation does not eliminate the problem of infection, since we must assume that the fracture is compounded from the wound of insertion of the nail even though it is some distance from the fracture. There is also the possibility of fat embolization; fortunately we have not had any such complication. Removal of the nail at a later date can be a rather formidable procedure if the medullary canal is small and the nail is deeply embedded in the bone. The method is of no help in fractures of the proximal and distal ends of the tibia. It is obvious that this method interferes partially with the endosteal circulation to the cortex of the tibia; it has been pointed out5 • 14 that two-thirds of the circulation to the cortex of the shaft of the tibia is supplied by the endosteal system. PREPARATION FOR BLIND NAILING
It is necessary to have the complete set designed by Lottes for this procedure: a complete set of nails, extensions, a driver and all of the equipment for extraction of the nail should the necessity arise. The tibial nail is a triflanged, heavy-cored stainless steel nail which comes in %-inch and 5/16-inch diameters and increments of ~ inch in length. The proximal and distal fifths of the nail are slightly curved. It is quite rigid but is slightly malleable so that it can be bent if necessary. The distal tip is partially rounded so that it will glide along the medullary canal, and the over-all design permits it to conform to the normal anatomical configuration of the tibia when properly inserted. The procedure is preferably carried out on a fracture table so that fixed, strong traction and control of the fractured tibia can be maintained. It can be performed over the end of the table, but this is not recommended. It is highly recommended that the operator become thoroughly familiar with the technique, practice it by using a tibia from a supra-
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condylar amputation and observe the performance of one who is experienced in the procedure. POSITIONING AND DRAPING OF THE PATIENT ON THE TABLE
The patient is placed on the fracture table and anesthetized with either a spinal or a general anesthetic. He is then placed in a supine position. The uninvolved extremity is placed in light traction and abduction to remove it from the fractured extremity and also to help stabilize the patient on the table. The fractured extremity is positioned so that the hip is flexed approximately 50 degrees and the knee approximately A
B
D Fig. 2. A, The foot of the fractured extremity is firmly attached to the foot plate and firm traction applied. No tourniquet is used. B, The foot is rotated to bring the crest in line. C, The extremity is draped to permit adequate exposure for visualization, reduction and x-rays. D, The nail is passed by'hand down the proximal one-third of the tibia, maintaining the anterior flange of the nail parallel to the crest of the tibia.
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90 degrees over a knee holder or sling from an overhead bar. The foot is very securely fixed in the foot plate and is taped in position with I-inch tape so that it will not slip. Figure 2, A, shows the proper~position of the patient on the table. Reduction is now carried out by securing fairly strong traction on the foot and lining up the tibial crest as shown in Figure 2, B. Rotation of the distal fragment is adjusted so that the tibial crest is in line. The entire leg is now completely prepared and draped free so that x-ray plates can be placed about it (Fig. 2, C). OPERATIVE PROCEDURE
The procedure which we follow is that originally outlined by Lottes. 7, 8, 9 A longitudinal incision is made one fingerbreadth medial to the tibial tubercle, extending from the mid portion of the tubercle proximally for 3 inches. The bone is exposed by subperiosteal dissection up to the knee joint, but only the subcutaneous tissue is incised above the tibial plateau in order to avoid entering the joint. A small, self-retaining retractor is then used. A %-inch hole is started through the cortex of the upper tibia at a point a few millimeters above the upper portion of the tibial tubercle at a small plateau which lies approximately 1.5 centimeters below the articular margin of the tibia. A curved plate is inserted between the drill and the knee to protect the soft tissues. The drill is started at a right angle and, as it penetrates the cortex, the tip is angled distally while drilling continues so that it eventually is aimed down the shaft of the tibia. This actually cuts a groove or rather markedly slanted hole through the cortex of the tibia so that it is very thin anteriorly. A brace type drill is best for this procedure. The proper length of the nail should have been previously determined on the normal extremity. This is done by measuring the distance from the drop-off of the medial malleolus to the upper portion of the tibial tubercle, because the distal end of an accurately and well inserted nail should be % of an inch from the ankle joint. The nail is inserted by hand, and one must be certain to direct the nail down the shaft of the tibia, depressing the base of the nail toward the knee joint and properly protecting the soft tissues with the curved plate. The anterior flange of the nail should parallel the tibial crest. One should be able to pass the nail through the upper third of the tibia by hand (Fig. 2, D). The driver is attached and the nail is inserted by fairly forceful blows of the hammer. The penetration of the nail can readily be determined by holding a nail of similar length externally. The nail is driven down to the fracture site. The operator now reduces the fracture while an assistant drives the nail across the fracture line. Maintenance of the reduction of the fracture is of utmost importance; proficient accomplish-
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ment of this requires some experience and careful analysis of the x-rays. If the fracture is transverse, the crest must be held in line. In an oblique
fracture, the reduction must be maintained by forcefully opposing the surfaces of the fracture together so that they are not displaced when the nail is driven approximately 2 inches past the fracture line. In fractures above the mid portion of the tibia, the distal fragment should be displaced posteriorly in order to accept the oncoming nail. In fractures distal to the mid portion of the tibia, the distal fragment should be displaced slightly anteriorly in order to accept the oncoming nail. This is essential because of the shape of the nail. X-rays are taken to see whether the nail is in the distal fragment. One can usually be fairly certain by moving the bone about. If the nail is in the distal segment, the fracture usually is quite stable; if it is not, there is usually excessive motion and a clicking sound. If the nail is in the distal fragment, it is driven home. The nail meets most resistance at the junction of the distal and middle thirds of the tibia, where the medullary canal is narrowest. The larger diameter nail (VB-inch) is almost always used. If it binds so that it does not move with a forceful blow of the hammer, it is removed and the smaller diameter nail is inserted. One must be very careful to note whether or not the nail is penetrating with each blow of the hammer. This is the best method of determining whether the nail will be accepted by the canal. As the nail is driven in, the driver is gradually unscrewed so that the threads will lie below the surface of the bone. Otherwise, the patient will have a tender, painful area over the base of the nail. If the nail is not in the distal fragment, it should be withdrawn and again inserted. After three unsuccessful tries, a small incision should be made over the fracture site and the nailing carried out with the fracture exposed rather than by the blind method. An osteotomy of the fibula is not done. It is now important to remove the traction and permit impaction of the bone ends. When this occurs, the base of the nail usually comes up out of the hole of insertion and the nail has to be again driven in deeper. X-rays are taken to make certain that the tip of the nail is approximately %:' of an inch from the ankle joint. The wound is closed in the usual fashion and the patient is placed in a long leg cast which is flexed 35 degrees at the knee. POSTOPERATIVE CARE
The patient is placed up in slings postoperatively. He is permitted to get up on crutches as soon as returning strength and diminishing discomfort permit him to do so. After 10 to 14 days the cast is changed, the sutures are removed and a long leg cast is applied with the knee in full extension but not in hyperextension. Minimal padding is used and
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the cast is carefully molded about the femoral condyles and patella to control rotation. If angulation of the tibia exists at this time, it can be corrected in order to align the tibia properly. Should this be necessary, an anesthetic is usually essential. A walker is applied to the cast. The .patient is ambulated with weight bearing as soon as pain permits. Some patients can begin full weight bearing within a few days or weeks; others never obtain full weight bearing because of discomfort. Full weight bearing is not permitted unless at least one-third of the contacting cortex is intact. It is usually permissible to remove the cast in about eight weeks. It can be left off if x-rays show adequate early healing and no loss of position and if there is minimal bone tenderness. METHODS OF HANDLING VARIOUS TYPES OF FRACTURES
The closed fresh fracture is treated as soon as the patient's general condition permits-if possible, within the first 24 hours following injury. The blind technique is used when feasible (Fig, 3). The extremity must be splinted with a long leg cast if there is a delay in nailing to lessen motion and to avoid swelling or over-riding of the fragments so that shortening of the soft tissue will hot 'occur. The intact skin is also preserved much better by proper external splinting. The leg is kept elevated in slings until the patient's condition permits the procedure to be carried out. Compound fractures are handled as emergencies and nailing carried
Fig, 3. E.V., age 34, white female, closed fracture nailed blindly with 5/16-inch diameter nail. The cast was worn for 2 months. Unrestricted full weight bearing was permitted at 3 months. The nail was removed at 8 months because it was too long and painful. A, Prenailing x-ray. B, Four months post nailing.
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JR.
Fig. 4. L.J., age 78, colored male, severely compounded segmental fracture which was nailed immediately with dtbridement of the wound. He required a pedicle flap and multiple skin grafts over a 2-month period to secure wound coverage. A cast was used for 5 months. Partial weight bearing was begun at 3 month in the cast. Eventual union was obtained at 8 months with full weight bearing. A, Prenailing x-ray. B, Post nailing x-ray in cast.
Fig. 5. G.Y., age 57, white male, open nonunion 21 months old. ailing, iliac grafts and osteotomy of fibula were carried out at one procedure. The patient was allowed full weight bearing in a cast in ,30 days. The cast was worn for 10 months. A, Prenailing x-ray. B, ine months post nailing. The patient had no further difficulty.
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out as quickly as possible, preferably within the first eight hours. The wound of compounding is treated by conservative debridement of skin and bone and radical debridement of fascia and muscle. The open wound is used to palpate the fracture site during the nailing but it is not enlarged for this purpose (Fig. 4). If debridement is adequate, the wound is closed primarily but loosely. Should the patient's general condition not permit nailing at this time, the wound is debrided and closed primarily if the responsible surgeon feels that it is proper to do so. The patient should be kept under strict observation. If there is any doubt, the wound is packed open with dry, fine mesh gauze. The wound can then be closed by delayed primary closure. The nailing can be carried out at that time. When there is a delay in nailing, the sutures are left in place during the nailing and are removed when the wound is well healed. If the patient has delayed union or nonunion with intact skin, the fracture site is exposed through a medial incision not over the bone. The sclerotic ends are excised and the medullary canal is drilled with a VB-inch drill in order to accept the nail. To permit proper contact of the bone ends upon weight bearing, a resection of a portion of the fibula or an oblique osteotomy through a separate incision is performed. The nailing is done on a standard operating room table. Homologous Phemister type grafts are applied from the patient's ilium. The wound is closed primarily. The patient is treated in the same way as if a primary nailing had been done, although external fixation is maintained for a considerably longer time. If infection occurs, the wound is opened, adequate drainage established and the nail left in place until union is achieved. After adequate healing of the fracture, the nail can be removed and sequestrations performed as necessary. In compound, chronically infected fractures with nonunion, our results have not been as satisfactory in using the nail as we had hoped. In defense of the nail, however, it must be stated that these patients are doomed to amputation; nailing is a last resort. It also must be added that there is' not adequate soft tissue closure over these wounds and usually some portion of the tibia has sequestered. The nail is also exposed. In our experience, there have been four such patients, three of whom went on to eventual amputation. Drainage continued to be severe after nailing in these three cases. In one case, the nail migrated into the ankle joint causing infection of this joint. Generally, we have been unsuccessful in a final salvage procedure in cases of chronic, open, draining nonunion with osteomyelitis. However, it is our opinion that the use of the nail in this type of case is justified because no other method of treatment has proved more satisfactory. The successful case is shown in Figure 5.
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Fig. 6. E.F., age 57, colored male, closed fracture nailed blindly. The complication of lateral angulation of the distal fragment was encountered because the nail was not large enough in diameter. The cast was removed and full weight bearing was attained in 3 months. The patient has complained of mild ankle strain from his valgus angulation.
COMPLICATIONS AND DIFFICULTIES
In our experience, there have been no serious complications with this method of internal fixation. Others have had serious complications such as vascular insufficiency resulting in gangrene and amputation following attempts to use the closed method. 2 A difficulty which may be frequently encountered is the inability to perform the nailing blindly. However, if one carries out the method specifically as recommended by Lottes, using fixed traction on a satisfactory fracture table and with particular attention to details, nailing can almost always be done blindly. Should it be necessary to open the fracture site, a considerable advantage of this method is lost because wounds in this area often break down. IS The correct diameter for the nail may be difficult to determine. Usually the larger nail is used. If the nail becomes jammed and binds too tightly, it can be very difficult to extract. The nail may also shatter or split the tibia. If this occurs, an advantage of this method of internal fixation obviously is lost. If the canal is too large for the nail, angulation of the bone can occur at the fracture site. We have encountered this trouble on two occasions. Theoretically it can be corrected by bending the nail and realigning the tibia. However, we did not do this because the lateral angulation of the distal segment was so small that we did not deem correction to be necessary (Fig. 6). The nail may bend if sufficient stress is applied to it. One patient had this occur during an altercation; consequently the leg had to be straightened and a new nail inserted (Fig. 7). The nail may back out upon weight bearing, causing irritation and a
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Fig. 7. G.S., age 24, closed fresh oblique fracture with bending of a previously in erted nail for a transverse fracture. This occurred 6 months post nailing during an altercation. A new nail was inserted with satisfactory union of the new oblique fracture in 3 months. A, Recent oblique fracture with bent nail in place. B, Three months post insertion of new nail.
Fig. 8. W.W., age 57, white male, closed fracture. Blind nailing was performed with satisfactory union at 3 months. The cast was removed in 10 weeks. There was a mild complication of recurvatum which was asymptomatic. This was probably secondary to a short nail.
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painful bursa at the site of insertion, often necessitating removal of the nail as soon as healing has occurred. In our experience, only a very few patients have required removal of the nail. This is not done until at least one year has elapsed following the nailing. Ten per cent of our cases show a mild recurvatum or posterior bowing with the nail in place (Fig. 8). This has not caused any symptoms. It can usually be prevented by using a nail of proper length. With impaction of the fracture, the tip of the nail may penetrate through the ankle joint and cause a traumatic arthritis of the joint. This occurred in only one patient with chronic infection. The use of the nail did not help as a final salvage procedure in most of the patients with severe, chronic osteomyelitis and open nonunions. SUMMARY
We have had experience with the Lottes method of internal fixation in 48 cases, and we believe that it is an excellent method in fractures of the shaft of the tibia. The complications have been minimal. The method is not difficult if it is properly studied and understood. One delayed union occurred but this went on to eventual union. The method has been of great help in unstable fractures, segmental fractures and pathological fractures. When the method is properly performed, it preserves the skin and certainly provides excellent fixation and early clinical union. REFERENCES 1. Boylston, B. F. and Milam, R.: Segmental Fractures of Tibia. South. M. J.
50: 969-975, 1957. 2. Carpenter, E. and Butterworth, J. F.: Conservative Treatment of Shaft Fractures of Tibia and Fibula. South. M. J. 50: 1209-1214, 1957. 3. Crawford, J. R.: Intramedullary Fixation of Fractures of Shaft of Tibia with Lottes Nail. J. Maine M. A. 47: 269-272, 1956. 4. Hampton, O. P. and Holt, E. P.: Present Status of Intramedullary Nailing of Fractures of Tibia. Am. J. Surg. 93: 597-603, 1957. 5. Jackson, R. W. and Macnab, 1.: Fractures of Shaft of Tibia. A Clinical and Experimental Study. Am. J. Surg. 97: 543-557, 1959. 6. Jocson, C. T.: Fractures of Shaft of Tibia in Adults Treated with Multiple Wire Fixation. Am. J. Surg. 94: 747-756, 1957. 7. Lottes, J. 0.: Intramedullary Fixation for Fractures of Shaft of Tibia. South M. J. 45: 407-414, 1952. 8. Lottes, J. 0.: Blind Nailing Technique for Insertion of Triflange Medullar Nail. J.A.M.A. 155: 1039-1042, 1954. 9. Lottes, J. 0., Hill, L. J. and Key, J. A.: Closed Reduction, Plate Fixation, and Medullary Nailing of Fractures of Both Bones of the Leg. A Comparative End-Result Study. J. Bone & Joint Surg. 34A: 861-877, 1952. 10. Marek, F. M.: Non-union and Mal-union of Shaft of Tibia Treated by Local Freshening, Iliac Bone Graft and Intramedullary Nailing. Bull. Hosp. for Joint Dis. 27: 87-94, 1956. 11. Marek, F. M.: Treatment of Fractures of Shaft of Tibia by Intramedullary Fixation with Lottes Nail. Am. J. Surg. 91: 204-210,1956.
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12. Miller, J. W. and Reed, F. N.: Current Trends in Treatment of Tibial Shaft Fractures. Arch. Surg. 15: 243-248, 1957. 13. Moorehead, S. F. and Mays, O. A.: Fractures of Tibial Shaft. South. M. J. 50: 289-293, 1957. 14. Rhinelander, F. W.: Microangiography in Fracture Healing. In preparation for publication. 15. Shanewise, R. P.: Intramedullary Nailinf for Tibial Fractures. Northwest Med. 58: 985-986, 1959. 16. Stephens, J. B. and Andersen, M. N.: Analysis of Open and Closed Treatment of Fractures of Tibial Shaft. Canad. J. Surg. 4: 65-68,1960. 17. Travis, L. 0.: Tibial Shaft Fractures-Problems in Management. J.A.M.A. 164: 1175-1180, 1957. 18. Urist, M. R., Mazet, R. and McLean, F. C.: Pathogenesis and Treatment of Delayed Union and Non-Union. A Survey of Eighty-Five Ununited Fractures of Shaft of Tibia and One Hundred Control Cases with Similar Injuries. J. Bone & Joint Surg. S6A: 931-968, 1954. 19. Veliskakis, K. P.: Primary Internal Fixation in Open Fractures of Tibial Shaft. The Problem of Wound Healing. J. Bone & Joint Surg. 41B: 342-354,1959. 20. Wheeler, J. E.: Treatment of Tibial Fractures by Multiple Medullary Wire Fixation. South. M. J. 50: 294-296, 1957. 2065 Adelbert Road Cleveland 6, Ohio
GEORGE E. SPENCER, JR., M.D. Assistant Professor of Orthopaedic Surgery
THE USE of intramedullary fixation for fractures of the shaft of the tibia still remains a somewhat controversial subject. Many surgeons and clinics are highly enthusiastic about this method of therapYj4. 11. 20 others condemn it vigorously and point out that the original users of intramedullary nailing for long bones, Kuntscher and Buehler, have abandoned the technique for fixation of fractures of the shaft of the tibia. 2 • I. The recent literature on this subject indicates that the method as described by Lottes 7 • 8 appears to be by far the most accepted and successful method of intramedullary nailing of the tibia. 3 • 4 In recent studies and reports regarding open reduction of the shaft of the tibia, most authors have indicated that the best method of internal fixation for tibial shaft fractures is the intramedullary nail. 9 • 17 We believe that this method is excellent when internal fixation becomes necessary in treating fractures of the shaft of the tibia. A closed reduction should be obtained and maintained if at all possible but, if this fails, the blind nailing method of Lottes is preferred in those fractures where internal fixation is indicated. Our experience has been confined to the use of the Lottes type nail for intramedullary fixation of the shaft of the tibia. INDICATIONS
The method can be used for any fracture of the shaft of the tibia from the junction of the upper and middle third to within 3 inches of the ankle joint. It functions most effectively and efficiently in fractures of the middle third of the shaft of the tibia. It is particularly helpful in segmental fractures because one of the fractures is almost always in this
1531
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GEORGE
E.
SPENCER, JR.
Fig. 1. E.J., age 59, white female, closed pathological fracture from metastatic tumor of uterus. X-ray therapy was given. No cast was necessary. The patient died 6 months post nailing, never having achieved full weight bearing.
area. There appears to be no advantage to using this method in fractures of the upper third or the distal end of the tibia. One point must be qualified, however: There must be an adequate medullary canal. Paget's disease, fibrous dysplasia or any sclerotic lesion may obliterate the medullary canal. ADVANTAGES
The blind method of insertion should be adhered to as advocated by Lottes. If this is not done, many of the advantages of the method are lost. Blind insertion preserves the skin over the fracture site. This is most important because the skin is usually subject to necrosis and the circulation to the skin of the lower third of the leg is usually precarious. The method also preserves the skin as the best dressing over the fracture. The circulation to the cortex of the tibia is disturbed much less than if an open reduction is performed. It is important to preserve the periosteal circulation because intramedullary fixation compromises the endosteal blood supply, and the periosteal circulation must then contribute most of the circulation. As pointed out by Jackson and Macnab,5 the periosteal supply is very important in formation of the callus of a fracture of the shaft of the tibia. Early ambulation with weight bearing can be achieved more quickly and the stress factor, which is so important in the union of fractures, may be instituted earlier. The patient's leg is immobilized in a cast for an average of eight weeks, which is considerably shorter than if external fixation alone is used. It is thought that earlier union is obtained, but this point can be debated. From a clinical standpoint, union occurs earlier, for the patient can bear full weight out of his cast sooner and can perform in a more normal manner.
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The nail has a distinct advantage in segmental fractures, l for these are unstable and any other form of internal fixation requires considerable dissection of the soft parts. The method has proved to be of great advantage in pathological fractures because the entire shaft of the bone is used to stabilize the fracture; unless the entire bone is involved, this method offers the best means of internal fixation available (Fig. 1). It has proved to be a great help in fractures which require a cross-leg flap to gain soft tissue coverage and other similar procedures in which external fixation alone would not efficiently provide adequate stabilization of the fractured tibia. The method can be used in fresh fractures, compound fractures and delayed unions and nonunions. Because of the intramedullary position of the nail, there is less bulk and it is easier to place bone grafts about the fracture site. DISADVANTAGES
The blind method of internal fixation does not eliminate the problem of infection, since we must assume that the fracture is compounded from the wound of insertion of the nail even though it is some distance from the fracture. There is also the possibility of fat embolization; fortunately we have not had any such complication. Removal of the nail at a later date can be a rather formidable procedure if the medullary canal is small and the nail is deeply embedded in the bone. The method is of no help in fractures of the proximal and distal ends of the tibia. It is obvious that this method interferes partially with the endosteal circulation to the cortex of the tibia; it has been pointed out5 • 14 that two-thirds of the circulation to the cortex of the shaft of the tibia is supplied by the endosteal system. PREPARATION FOR BLIND NAILING
It is necessary to have the complete set designed by Lottes for this procedure: a complete set of nails, extensions, a driver and all of the equipment for extraction of the nail should the necessity arise. The tibial nail is a triflanged, heavy-cored stainless steel nail which comes in %-inch and 5/16-inch diameters and increments of ~ inch in length. The proximal and distal fifths of the nail are slightly curved. It is quite rigid but is slightly malleable so that it can be bent if necessary. The distal tip is partially rounded so that it will glide along the medullary canal, and the over-all design permits it to conform to the normal anatomical configuration of the tibia when properly inserted. The procedure is preferably carried out on a fracture table so that fixed, strong traction and control of the fractured tibia can be maintained. It can be performed over the end of the table, but this is not recommended. It is highly recommended that the operator become thoroughly familiar with the technique, practice it by using a tibia from a supra-
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E.
SPENCER, JR.
condylar amputation and observe the performance of one who is experienced in the procedure. POSITIONING AND DRAPING OF THE PATIENT ON THE TABLE
The patient is placed on the fracture table and anesthetized with either a spinal or a general anesthetic. He is then placed in a supine position. The uninvolved extremity is placed in light traction and abduction to remove it from the fractured extremity and also to help stabilize the patient on the table. The fractured extremity is positioned so that the hip is flexed approximately 50 degrees and the knee approximately A
B
D Fig. 2. A, The foot of the fractured extremity is firmly attached to the foot plate and firm traction applied. No tourniquet is used. B, The foot is rotated to bring the crest in line. C, The extremity is draped to permit adequate exposure for visualization, reduction and x-rays. D, The nail is passed by'hand down the proximal one-third of the tibia, maintaining the anterior flange of the nail parallel to the crest of the tibia.
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90 degrees over a knee holder or sling from an overhead bar. The foot is very securely fixed in the foot plate and is taped in position with I-inch tape so that it will not slip. Figure 2, A, shows the proper~position of the patient on the table. Reduction is now carried out by securing fairly strong traction on the foot and lining up the tibial crest as shown in Figure 2, B. Rotation of the distal fragment is adjusted so that the tibial crest is in line. The entire leg is now completely prepared and draped free so that x-ray plates can be placed about it (Fig. 2, C). OPERATIVE PROCEDURE
The procedure which we follow is that originally outlined by Lottes. 7, 8, 9 A longitudinal incision is made one fingerbreadth medial to the tibial tubercle, extending from the mid portion of the tubercle proximally for 3 inches. The bone is exposed by subperiosteal dissection up to the knee joint, but only the subcutaneous tissue is incised above the tibial plateau in order to avoid entering the joint. A small, self-retaining retractor is then used. A %-inch hole is started through the cortex of the upper tibia at a point a few millimeters above the upper portion of the tibial tubercle at a small plateau which lies approximately 1.5 centimeters below the articular margin of the tibia. A curved plate is inserted between the drill and the knee to protect the soft tissues. The drill is started at a right angle and, as it penetrates the cortex, the tip is angled distally while drilling continues so that it eventually is aimed down the shaft of the tibia. This actually cuts a groove or rather markedly slanted hole through the cortex of the tibia so that it is very thin anteriorly. A brace type drill is best for this procedure. The proper length of the nail should have been previously determined on the normal extremity. This is done by measuring the distance from the drop-off of the medial malleolus to the upper portion of the tibial tubercle, because the distal end of an accurately and well inserted nail should be % of an inch from the ankle joint. The nail is inserted by hand, and one must be certain to direct the nail down the shaft of the tibia, depressing the base of the nail toward the knee joint and properly protecting the soft tissues with the curved plate. The anterior flange of the nail should parallel the tibial crest. One should be able to pass the nail through the upper third of the tibia by hand (Fig. 2, D). The driver is attached and the nail is inserted by fairly forceful blows of the hammer. The penetration of the nail can readily be determined by holding a nail of similar length externally. The nail is driven down to the fracture site. The operator now reduces the fracture while an assistant drives the nail across the fracture line. Maintenance of the reduction of the fracture is of utmost importance; proficient accomplish-
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GEORGE
E.
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ment of this requires some experience and careful analysis of the x-rays. If the fracture is transverse, the crest must be held in line. In an oblique
fracture, the reduction must be maintained by forcefully opposing the surfaces of the fracture together so that they are not displaced when the nail is driven approximately 2 inches past the fracture line. In fractures above the mid portion of the tibia, the distal fragment should be displaced posteriorly in order to accept the oncoming nail. In fractures distal to the mid portion of the tibia, the distal fragment should be displaced slightly anteriorly in order to accept the oncoming nail. This is essential because of the shape of the nail. X-rays are taken to see whether the nail is in the distal fragment. One can usually be fairly certain by moving the bone about. If the nail is in the distal segment, the fracture usually is quite stable; if it is not, there is usually excessive motion and a clicking sound. If the nail is in the distal fragment, it is driven home. The nail meets most resistance at the junction of the distal and middle thirds of the tibia, where the medullary canal is narrowest. The larger diameter nail (VB-inch) is almost always used. If it binds so that it does not move with a forceful blow of the hammer, it is removed and the smaller diameter nail is inserted. One must be very careful to note whether or not the nail is penetrating with each blow of the hammer. This is the best method of determining whether the nail will be accepted by the canal. As the nail is driven in, the driver is gradually unscrewed so that the threads will lie below the surface of the bone. Otherwise, the patient will have a tender, painful area over the base of the nail. If the nail is not in the distal fragment, it should be withdrawn and again inserted. After three unsuccessful tries, a small incision should be made over the fracture site and the nailing carried out with the fracture exposed rather than by the blind method. An osteotomy of the fibula is not done. It is now important to remove the traction and permit impaction of the bone ends. When this occurs, the base of the nail usually comes up out of the hole of insertion and the nail has to be again driven in deeper. X-rays are taken to make certain that the tip of the nail is approximately %:' of an inch from the ankle joint. The wound is closed in the usual fashion and the patient is placed in a long leg cast which is flexed 35 degrees at the knee. POSTOPERATIVE CARE
The patient is placed up in slings postoperatively. He is permitted to get up on crutches as soon as returning strength and diminishing discomfort permit him to do so. After 10 to 14 days the cast is changed, the sutures are removed and a long leg cast is applied with the knee in full extension but not in hyperextension. Minimal padding is used and
Intramedullary Fixation in Fractures of Tibia
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the cast is carefully molded about the femoral condyles and patella to control rotation. If angulation of the tibia exists at this time, it can be corrected in order to align the tibia properly. Should this be necessary, an anesthetic is usually essential. A walker is applied to the cast. The .patient is ambulated with weight bearing as soon as pain permits. Some patients can begin full weight bearing within a few days or weeks; others never obtain full weight bearing because of discomfort. Full weight bearing is not permitted unless at least one-third of the contacting cortex is intact. It is usually permissible to remove the cast in about eight weeks. It can be left off if x-rays show adequate early healing and no loss of position and if there is minimal bone tenderness. METHODS OF HANDLING VARIOUS TYPES OF FRACTURES
The closed fresh fracture is treated as soon as the patient's general condition permits-if possible, within the first 24 hours following injury. The blind technique is used when feasible (Fig, 3). The extremity must be splinted with a long leg cast if there is a delay in nailing to lessen motion and to avoid swelling or over-riding of the fragments so that shortening of the soft tissue will hot 'occur. The intact skin is also preserved much better by proper external splinting. The leg is kept elevated in slings until the patient's condition permits the procedure to be carried out. Compound fractures are handled as emergencies and nailing carried
Fig, 3. E.V., age 34, white female, closed fracture nailed blindly with 5/16-inch diameter nail. The cast was worn for 2 months. Unrestricted full weight bearing was permitted at 3 months. The nail was removed at 8 months because it was too long and painful. A, Prenailing x-ray. B, Four months post nailing.
1538
GEORGE
E.
SPENCER,
JR.
Fig. 4. L.J., age 78, colored male, severely compounded segmental fracture which was nailed immediately with dtbridement of the wound. He required a pedicle flap and multiple skin grafts over a 2-month period to secure wound coverage. A cast was used for 5 months. Partial weight bearing was begun at 3 month in the cast. Eventual union was obtained at 8 months with full weight bearing. A, Prenailing x-ray. B, Post nailing x-ray in cast.
Fig. 5. G.Y., age 57, white male, open nonunion 21 months old. ailing, iliac grafts and osteotomy of fibula were carried out at one procedure. The patient was allowed full weight bearing in a cast in ,30 days. The cast was worn for 10 months. A, Prenailing x-ray. B, ine months post nailing. The patient had no further difficulty.
Intramedullary Fixation in Fractures of Tibia
1539
out as quickly as possible, preferably within the first eight hours. The wound of compounding is treated by conservative debridement of skin and bone and radical debridement of fascia and muscle. The open wound is used to palpate the fracture site during the nailing but it is not enlarged for this purpose (Fig. 4). If debridement is adequate, the wound is closed primarily but loosely. Should the patient's general condition not permit nailing at this time, the wound is debrided and closed primarily if the responsible surgeon feels that it is proper to do so. The patient should be kept under strict observation. If there is any doubt, the wound is packed open with dry, fine mesh gauze. The wound can then be closed by delayed primary closure. The nailing can be carried out at that time. When there is a delay in nailing, the sutures are left in place during the nailing and are removed when the wound is well healed. If the patient has delayed union or nonunion with intact skin, the fracture site is exposed through a medial incision not over the bone. The sclerotic ends are excised and the medullary canal is drilled with a VB-inch drill in order to accept the nail. To permit proper contact of the bone ends upon weight bearing, a resection of a portion of the fibula or an oblique osteotomy through a separate incision is performed. The nailing is done on a standard operating room table. Homologous Phemister type grafts are applied from the patient's ilium. The wound is closed primarily. The patient is treated in the same way as if a primary nailing had been done, although external fixation is maintained for a considerably longer time. If infection occurs, the wound is opened, adequate drainage established and the nail left in place until union is achieved. After adequate healing of the fracture, the nail can be removed and sequestrations performed as necessary. In compound, chronically infected fractures with nonunion, our results have not been as satisfactory in using the nail as we had hoped. In defense of the nail, however, it must be stated that these patients are doomed to amputation; nailing is a last resort. It also must be added that there is' not adequate soft tissue closure over these wounds and usually some portion of the tibia has sequestered. The nail is also exposed. In our experience, there have been four such patients, three of whom went on to eventual amputation. Drainage continued to be severe after nailing in these three cases. In one case, the nail migrated into the ankle joint causing infection of this joint. Generally, we have been unsuccessful in a final salvage procedure in cases of chronic, open, draining nonunion with osteomyelitis. However, it is our opinion that the use of the nail in this type of case is justified because no other method of treatment has proved more satisfactory. The successful case is shown in Figure 5.
1540
GEORGE
E.
SPENCER, JR.
Fig. 6. E.F., age 57, colored male, closed fracture nailed blindly. The complication of lateral angulation of the distal fragment was encountered because the nail was not large enough in diameter. The cast was removed and full weight bearing was attained in 3 months. The patient has complained of mild ankle strain from his valgus angulation.
COMPLICATIONS AND DIFFICULTIES
In our experience, there have been no serious complications with this method of internal fixation. Others have had serious complications such as vascular insufficiency resulting in gangrene and amputation following attempts to use the closed method. 2 A difficulty which may be frequently encountered is the inability to perform the nailing blindly. However, if one carries out the method specifically as recommended by Lottes, using fixed traction on a satisfactory fracture table and with particular attention to details, nailing can almost always be done blindly. Should it be necessary to open the fracture site, a considerable advantage of this method is lost because wounds in this area often break down. IS The correct diameter for the nail may be difficult to determine. Usually the larger nail is used. If the nail becomes jammed and binds too tightly, it can be very difficult to extract. The nail may also shatter or split the tibia. If this occurs, an advantage of this method of internal fixation obviously is lost. If the canal is too large for the nail, angulation of the bone can occur at the fracture site. We have encountered this trouble on two occasions. Theoretically it can be corrected by bending the nail and realigning the tibia. However, we did not do this because the lateral angulation of the distal segment was so small that we did not deem correction to be necessary (Fig. 6). The nail may bend if sufficient stress is applied to it. One patient had this occur during an altercation; consequently the leg had to be straightened and a new nail inserted (Fig. 7). The nail may back out upon weight bearing, causing irritation and a
Intramedullary Fixation in Fractures of Tibia
1541
Fig. 7. G.S., age 24, closed fresh oblique fracture with bending of a previously in erted nail for a transverse fracture. This occurred 6 months post nailing during an altercation. A new nail was inserted with satisfactory union of the new oblique fracture in 3 months. A, Recent oblique fracture with bent nail in place. B, Three months post insertion of new nail.
Fig. 8. W.W., age 57, white male, closed fracture. Blind nailing was performed with satisfactory union at 3 months. The cast was removed in 10 weeks. There was a mild complication of recurvatum which was asymptomatic. This was probably secondary to a short nail.
1542
GEORGE
E.
SPENCER, JR.
painful bursa at the site of insertion, often necessitating removal of the nail as soon as healing has occurred. In our experience, only a very few patients have required removal of the nail. This is not done until at least one year has elapsed following the nailing. Ten per cent of our cases show a mild recurvatum or posterior bowing with the nail in place (Fig. 8). This has not caused any symptoms. It can usually be prevented by using a nail of proper length. With impaction of the fracture, the tip of the nail may penetrate through the ankle joint and cause a traumatic arthritis of the joint. This occurred in only one patient with chronic infection. The use of the nail did not help as a final salvage procedure in most of the patients with severe, chronic osteomyelitis and open nonunions. SUMMARY
We have had experience with the Lottes method of internal fixation in 48 cases, and we believe that it is an excellent method in fractures of the shaft of the tibia. The complications have been minimal. The method is not difficult if it is properly studied and understood. One delayed union occurred but this went on to eventual union. The method has been of great help in unstable fractures, segmental fractures and pathological fractures. When the method is properly performed, it preserves the skin and certainly provides excellent fixation and early clinical union. REFERENCES 1. Boylston, B. F. and Milam, R.: Segmental Fractures of Tibia. South. M. J.
50: 969-975, 1957. 2. Carpenter, E. and Butterworth, J. F.: Conservative Treatment of Shaft Fractures of Tibia and Fibula. South. M. J. 50: 1209-1214, 1957. 3. Crawford, J. R.: Intramedullary Fixation of Fractures of Shaft of Tibia with Lottes Nail. J. Maine M. A. 47: 269-272, 1956. 4. Hampton, O. P. and Holt, E. P.: Present Status of Intramedullary Nailing of Fractures of Tibia. Am. J. Surg. 93: 597-603, 1957. 5. Jackson, R. W. and Macnab, 1.: Fractures of Shaft of Tibia. A Clinical and Experimental Study. Am. J. Surg. 97: 543-557, 1959. 6. Jocson, C. T.: Fractures of Shaft of Tibia in Adults Treated with Multiple Wire Fixation. Am. J. Surg. 94: 747-756, 1957. 7. Lottes, J. 0.: Intramedullary Fixation for Fractures of Shaft of Tibia. South M. J. 45: 407-414, 1952. 8. Lottes, J. 0.: Blind Nailing Technique for Insertion of Triflange Medullar Nail. J.A.M.A. 155: 1039-1042, 1954. 9. Lottes, J. 0., Hill, L. J. and Key, J. A.: Closed Reduction, Plate Fixation, and Medullary Nailing of Fractures of Both Bones of the Leg. A Comparative End-Result Study. J. Bone & Joint Surg. 34A: 861-877, 1952. 10. Marek, F. M.: Non-union and Mal-union of Shaft of Tibia Treated by Local Freshening, Iliac Bone Graft and Intramedullary Nailing. Bull. Hosp. for Joint Dis. 27: 87-94, 1956. 11. Marek, F. M.: Treatment of Fractures of Shaft of Tibia by Intramedullary Fixation with Lottes Nail. Am. J. Surg. 91: 204-210,1956.
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12. Miller, J. W. and Reed, F. N.: Current Trends in Treatment of Tibial Shaft Fractures. Arch. Surg. 15: 243-248, 1957. 13. Moorehead, S. F. and Mays, O. A.: Fractures of Tibial Shaft. South. M. J. 50: 289-293, 1957. 14. Rhinelander, F. W.: Microangiography in Fracture Healing. In preparation for publication. 15. Shanewise, R. P.: Intramedullary Nailinf for Tibial Fractures. Northwest Med. 58: 985-986, 1959. 16. Stephens, J. B. and Andersen, M. N.: Analysis of Open and Closed Treatment of Fractures of Tibial Shaft. Canad. J. Surg. 4: 65-68,1960. 17. Travis, L. 0.: Tibial Shaft Fractures-Problems in Management. J.A.M.A. 164: 1175-1180, 1957. 18. Urist, M. R., Mazet, R. and McLean, F. C.: Pathogenesis and Treatment of Delayed Union and Non-Union. A Survey of Eighty-Five Ununited Fractures of Shaft of Tibia and One Hundred Control Cases with Similar Injuries. J. Bone & Joint Surg. S6A: 931-968, 1954. 19. Veliskakis, K. P.: Primary Internal Fixation in Open Fractures of Tibial Shaft. The Problem of Wound Healing. J. Bone & Joint Surg. 41B: 342-354,1959. 20. Wheeler, J. E.: Treatment of Tibial Fractures by Multiple Medullary Wire Fixation. South. M. J. 50: 294-296, 1957. 2065 Adelbert Road Cleveland 6, Ohio