Osteosynthesis of 245 tibial shaft fractures: early and late complications

349

Osteosynthesis of 245 tibia1 shaft fractures: early and late complications C. Bilat, A. Leutenegger and T. Riiedi Department

of Surgery, Kantonsspital,

Chur, Switzerland

A consecutive series of 245 fresh fractures of the tibia1 shaft, including 60 open fractures underwent operation in a 5 year period (1980-I 984). Two hundred and forty-two (98.8 per cent) of these fractures were followed-up for an average of 79 months (6.5 years). Early and late complications as well as complications after implant removal were taken into account for closed and open fractures. In the 785 closed fractures, infection was observed in I. 7 per cent and delayed union in 6.8 per cent. More than 94 per cent of the closed fractures had an excellent OY good late result. In open fractures (60 cases) infection was seen in 6.8 per cent, and plate fatigue with delayed union was seen in 10.3 per cent. However an excellent OY good functional result was obtained in 93 per cent of the open fractures. After implant removal refractures occurred in 1.3 per cent and other minor complications in 0.9 per cent.

Injury, 1994,

Vol. 25, 349-358,

August

Number 70

60 50 40

30 20 10 0

Introduction Fractures of the tibia1 shaft are the most common long bone fractures and their treatment is probably the most discussed. This retrospective study of 245 operatively treated tibia1 shaft fractures recorded all early and late complications and their consequences as well as the functional result of the operative treatment. All complications after implant removal were recorded.

10

20

0

1994 Butterworth-Heinemann

0020-1383/94/060349-10

Ltd

50

60

70

80

90

Figure 1. Age and sex distribution of patients with tibia1 shaft fractures (N=238). n Men. q Women.

Sport accidents

During a 5-year period (1980-1984) a consecutive series of 245 fresh fractures of the tibial shaft in 238 patients was treated operatively at the Surgical Clinic, Ritisches Kantonsspital in Chur, Switzerland. Also included are fractures of the tibia1 shaft extending into the ankle joint or with involvement of the tibia plateau. Seven patients had bilateral tibia1 shaft fractures. In five cases both tibia1 fractures were stabilized with a dynamic compression plate (DCP) or an intramedullary nail. Two patients with multiple injuries and bilateral tibia1 fractures had initial stabilization with an external fixator. The average age of all patients was 35.9 years, ranging from 13 to 83 years. Fractures occurred in 159 males (64.9 per cent) and in 86 females (35.1 per cent) (Figure I).

40

Age

Table I. Circumstances

Patients

30

Traffic accidents

Industrial accidents Accidents at home

of accidents

(N= 238)

Skiing Other sport Motorcycle Pedestrian Car Bicycle Aeroplane

142 23 21 16 15 2 1 20 5

(58.0%) (9.4%) (8.6%) (6.5%) (6.1%) (0.8%) (0.4%) (8.2%) (2.0%)

Most fractures (67.4 per cent) were caused by sport, in particular skiing (58.0 per cent). Traffic accidents (22.4 per cent), industrial accidents (8.2 per cent) and accidents at home (2.0 per cent) were less important (Table I).

350

Injury: International Journal of the Care of the Injured (1994) Vol. 25/No. 6

Table II. Tibia1 shaft fractures in association with other injuries (N=

Table IV. Type of tibia1 shaft fracture (N= 245)

245)

Unilateral tibia1 shaft fractures (231 patients) Isolated injury Associated with other fractures Associated with multiple injuries (ES> 18) Bilateral tibia1 shaft fractures (7 patients) Isolated injury Associated with multiple injuries (ISS > 18)

201 9 21

(82.0%) (3.7%) (8.6%)

6 8

(2.4%) (3.3%)

(type A) (type B) (type C)

91 109 45

(37.2%) (44.5%) (18.3%)

Method Timing of surgery Primary stabilization as an emergency procedure was carried out in 233 fractures (95.1 per cent). The mean time between the accident and operation was 5 h. Twelve cases (4.9 per cent), including one Grade I open and one Grade II open fracture, were treated secondarily (Table V). In eight cases the severity of the closed soft tissue contusion made an emergency operation impossible and the injured limb was treated by elevation and immobilization. In four of these cases traction through a calcaneal pin was necessary. Two patients with isolated tibia1 shaft fractures were hospitalized a few days after the accident; one of them suffered from an ipsilateral purulent ingrowing toe nail, which required operation. The tibia1 shaft fracture was operated upon after the toe had completely healed. One fracture could not be fixed on the day of accident for logistical reasons. The average interval between accident and operation was 5 days, ranging from 2 to 18 days.

2,5 %

6,5 O/O

Figure 2. Classification of fractures (NC 245). Closed. Open Grade I. I3 Open Grade II. R Open Grade III.

@

Table III. Location of tibia1 shaft fractures (N= 245) Proximal third Middle third Distal third

Simple fracture Wedge fracture Complex fracture

19 136 90

(7.8%) (55.5%) (36.7%)

(82.0 per cent) the tibia1 shaft fracture In 201 patients was an isolated injury. In nine (3.7 per cent) the tibial shaft fractures were associated with one or more additional fracture, while 21 patients (8.6 per cent) were multiply injured (ISS 18 and more). In 14 cases (5.7 per cent) the tibia1 shaft fracture was bilateral, six (2.4 per cent) of them in patients without other injury, and eight (3.3 per cent) in patients with multiple injuries (Table II). The consecutive series included 185 closed (75.5 per cent) tibia1 fractures and 60 open (24.5 per cent) ones. The open fractures were subdivided into 16 (6.5 per cent) Grade I open, 38 (15.5 per cent) Grade II open and six (2.5 per cent) Grade III open fractures in accordance with the old A0 fracture classification of Miiller et al. (1977) (Figure 2). Nineteen fractures (7.8 per cent) were situated in the proximal third, 136 (55.5 per cent) in the middle third and 90 (36.7 per cent) in the distal third (TableHI) of the tibia1 shaft. In accordance with the A0 fracture classification of Miiller et al. (1990), 91 Type A or simple (37.2 per cent), 109 Type B or wedge (44.5 per cent) and 45 (18.3 per cent) Type C or complex fractures of the tibia1 shaft were observed (Table IV).

Choice of fixation device One hundred and ninety-seven (80.4 per cent) closed and open fractures were stabilized primarily with the DCP, 28 (11.4 per cent) with the standard A0 intramedullary nail, 16 (6.6 per cent) with the tubular external fixator, and four (1.6 per cent) with lag screws only (Table VI). The DCP was used for 155 closed, 12 Grade I open, 29 Grade II open and one Grade.111 open fractures. The plate was usually placed on the anteromedial aspect of the tibia. An anterolateral position was chosen in closed fractures with soft tissue contusion, in open fractures or other injuries on the medial aspect of the leg. Intramedullary nailing was performed in 24 closed and four Grade I open fractures. At that time (1980-1984) open nailing was still the preferred method. Lag screw fixation was chosen to stabilize four closed spiral fractures. Stabilization with an external fixator - mostly bilateral frames - was carried out in two closed fractures with severe soft tissue contusion, nine Grade II open and five Grade III open fractures. Additional interfragmentary lag screws were used in six cases. In eight patients the external fixator was later replaced by a DCP and in one instance by an intramedullary nail. In only three cases was complete healing achieved with an external fixator. One of these patients suffered from an infection of the tibia1 shaft at the time of the accident. The second had a Grade II open tibia1 fracture at three levels. His tibia was initially stabilized by calcaneal traction which was replaced after 19 days by an external fixator. The third patient had a closed fracture with severe soft tissue contusion. After healing of the soft tissue he refused to have his external fixator replaced by a plate. In three adolescents with Grade II and III open fractures, the external fixator was replaced by a cast after the soft tissue had healed. All open and secondarily stabilized closed fractures received prophylactic antibiotics perioperatively, while primarily fixed closed fractures never received antibiotics.

Bilat et al.: Osteosynthesis

351

of 245 tibia1 fractures

Table V. Time of operation of tibia1 shaft fractures (N= 245)

Primary Secondary

175 10

(within hours) (within days)

Total (N=245)

Open (N = 60)

Closed (N= 185)

58 2

(94.6%) (5.4%)

233 12

(96.7%) (3.3%)

(95.1%) (4.9%)

Table VI. Method of stabilization of tibia1 shaft fractures (NE 245) Open Grade I

Grade II

155 24 2 4

12 4

29

1 -

9

5

DCP lntramedullary nail External fixator Screws

Total

Grade 111

Closed

197 28 16 4

(80.4%) (11.4%) (6.6%) (1.6%)

DCP = dynamic compression plate.

Table VII. Follow up of 245 operated tibia1 shaft fractures Operated fractrues Post-operative death in multiple injuries (unilateral open fracture) Diet before follow up (patients with unilateral closed (4) and open (1) fractures Not reached (patients with unilateral closed fractures) Follow-up (personally 142. questionnaire 94)

In closed fractures, the deep fascia was usually readapted with primary wound closure after placement of a wound suction drain. In open fractures cleaning of damaged soft tissue was rather restricted. No case required more than a small resection of the contused skin edges. Extensive wound irrigation with saline and antiseptic solutions was carried out before and after stabilization. In open fractures stabilized with a DCP the skin incision was usually planned far away from the injury well to the lateral side of the tibia chest. Primary closure of the surgical incision was always achieved in these cases, while the wound caused by the injury was always left open. After-care

Postoperatively the limb was placed in an elevated position on a Braun frame for 5 days. The suction drain was removed after 24 h. Open wound care, without any dressing, was attempted after 24 h. Active and passive mobilization of the injured limb with a physiotherapist was started on the first postoperative day. After 5 days the patient could usually start to walk with partial weightbearing (10-15 kg). In 22 cases (9.0 per cent) additional stabilization with a below-knee cast was applied, the fracture being either too severely comminuted or the fixation unsatisfactory, or the patient appearing uncooperative. The average time of hospitalization for patients with isolated closed fractures was 10 days, ranging from 6 to 49 days and for patients with isolated open fractures 21 days, ranging from 7 to 105 days.

Follow up Out of 245 fractures in 238 patients, 236 fractures (96.3 per cent) in 235 patients were followed up. One hundred and

245 1 5 3 236

(100.0%) (0.4%) (2.0%) (1.2%) (96.4%)

forty-two fractures were followed up personally and 94 with the help of questionnaires. Where complications were mentioned, the physician or surgeon in charge was contacted for more detailed information. Three patients (1.2 per cent) with a unilateral closed fracture could not be reached in spite of an intensive search (Table VI). One patient with multiple injuries (ISS 66) and a unilateral tibia1 shaft fracture died within 16 h of the injury from heart failure. Five patients with unilateral fractures died before follow up. These deaths will be discussed in the Results. The average time of follow up after osteosynthesis of the tibia1 shaft fractures was 79 months, ranging from 48 to 108 months.

Results A 63-year-old patient with multiple injuries (ISS 66) and a unilateral Grade III open tibia1 shaft fracture, open skull fracture and cerebral contusion, ruptured liver, dislocation of the gall bladder, rib fractures and bilateral pulmonary contusions died a few hours after suture of liver, cholecystectomy and external fixation of the injured tibia, due to cardiac failure. This was the only case of death during hospitalization in the whole study. Four patients (1.6 per cent) with closed tibia1 shaft fractures and 1 (0.4 per cent) with a Grade II open tibia1 shaft fracture (average age 50 (20-73) years) died for reasons unrelated to the accident (three cardiac failure, one leukaemia, one traffic accident) prior to the actual follow up. In one of these cases, that with a Grade II open fracture, non-union persisted until his death. As already mentioned 22 operated fractures (9.0 per cent) required additional stabilization with a below-knee cast. Fourteen of these fractures healed without complica-

Injury: International Journal of the Care of the Injured (1994)

352 Table VIII. Results after osteosynthesis

Vol. 25/No. 6

of closed and open tibia1 shaft fractures (N= 236) Open (N=58)

Results (N=236)

Excellent Good Acceptable Poor

Closed (N=l78)

139 29 8 2

Grade I

Grade II

Grade Ill

10 4

22 12 3 -

2 3

(78.1%) (16.3%) (4.5%) (1.1%)

2

tions, but eight developed some complications in spite of the cast (three implant failures, two thrombophlebitis, one refracture, one delayed union, one axial deformity). Of these complications, three were clearly surgeon related (insufficient initial fracture fixation or poor soft tissue management) while three were patient related (poor compliance). The success of any form of treatment may probably best be judged by the functional outcome. We used the following criteria to classify our results (Table VIII): Excellent, complete restitution of anatomy and function with return to normal professional and recreational activities; Good, functional recovery compatible with normal professional and recreational activities; Acceptable, occasional complaints (pain, fatigue) with normal professional, but reduced recreational activities; Poor, limited function, significant pain, reduced activities or income.

Complications The complications were classified either as early (complications during initial hospitalization), late (complications between leaving hospital and implant removal), or complications after implant removal. Early complications

(Table IX)

In two closed (1.1 per cent) Partial wound dehiscence. and four open (6.8 per cent) tibia1 shaft fractures, partial wound dehiscence occurred a few days after surgery. In all cases uneventful healing occurred by prolonging the period of best rest and limb elevation. The wound was kept moist until secondary healing occurred. Postoperative haematoma. This complication occurred in nine closed (4.9 per cent) and one open (1.7 per cent)

Table IX. Early complications after operative closed and open tibia1 shaft fractures (N= 244)

treatment

Closed (N= 185) Wound dehiscence Post-operative haematoma Wound edge necrosis Deep venous thrombosis Deep infection (osteomyelitis)

2 9 2 2

(1.1%) (4.9%) (1.1%) (1.1%)

of

Open (N=59) 4 1 5 1 4

(6.8%) (1.7%) (8.5%) (1.7%) (6.8%)

-

Total open

34 19 3 2

(58.5%) (32.8%) (5.2%) (3.4%)

Total

173 48 11 4

(73.3%) (20.3%) (4.7%) (1.7%)

tibia1 shaft fracture. Application of ice and prolonged bedrest was again successful in resolving the problem. Wound edge necrosis. A partial necrosis of the wound edge occurred in five open (8.5 per cent) and two closed (1.1 per cent) fractures. In all five open fractures the necrosis developed around the initial wound and required secondary cleaning. All cases were treated successfully by immobilizing the limb and keeping the wound moist. Extensive cleaning or skin grafting was not necessary in any of these cases. One patient (1.7 per cent) Deep venous thrombosis. with an open and two (1.1per cent) with a closed tibia1 shaft fracture suffered post-operatively from a deep venous thrombosis of the operated limb. After confirmation of the clinical diagnosis by retrograde phlebography the treatment comprised full heparinization and subsequent anticoagulation with coumarin derivatives for 3 months. Deep infection (osteitis). Deep infection was observed in four out of 59 (6.8 per cent) open fractures (one Grade I and three Grade II), three of them fixed with a DCP, a few days after operation. In three instances extensive necrosis of the anteromedial soft tissues was present within 24 to 48 h after operation. In spite of generous cleaning, deep wound infection could not be avoided. Two patients required repeated surgical intervention, including cleaning, and sequestrectomy, and vascularized free flaps were necessary to obtain healing. In both cases the implants were removed after 4 months and replaced by a tubular external fixator (Figure 3). In the third case healing was achieved by additional cast treatment after healing of the soft tissues. The fourth patient suffered from a very contaminated Grade II open tibia1 shaft fracture in combination with an ipsilateral bimalleolar fracture after a crossroads accident. The tibia and fibula fractures were both stabilized as an emergency; however agressive gas gangrene developed after 24 h. Repeated extensive cleaning, sequestrectomy, partial resection of the fibula, resection of the medial malleolus, external fixator and finally fusion of the ankle joint were necessary to prevent amputation. One of these patients, who was 73 years old at follow up, was still being seen with the consequences of osteitis 8 years after the initial operation. He had a small persistent pretibial wound, but was practically without pain and had satisfactory function of his injured leg.

Bilat et al.: Osteosynthesis of 245 tibia1fractures

353

Figure 3. (a, b, c) Osteitis u, Grade II open tibia and fibula fracture. b, primary stabilization with a laterally placed DCP. c, 13 weeks after injury, signs of osteitis. (con@

Injury: International Journal of the Care of the Injured (1994) Vol. 25/No.

354

6

Figure 3 (contd) (d, e) d, Removal of the plate 17 weeks after injury and stabilization with a unilateral external fixator. e, 36 weeks after

injury, consolidation after sequestrectomy

and cancellous.bone

grafting. No recurrence of infection.

Table X. Late complications after operative treatment of closed and open tibia1 shaft fractures (N= 236) Closed (N=178)

Late infection (first manifestation 4 months or more after injury) Plate fatigue fracture with delayed-union Delayed union (without implant fatigue fracture) Malunion Deep venous thrombosis

Late complications

3

(1.7%)

3DCP

1 11

(0.6%) (6.2%)

1 DCP 8 DCP, 3 IMN -

2

(1.1%)

2 CP

(Table X)

Deep infection started in three closed Late infection. fractures (1.7 per cent) more than 4 months after stabilization with a DCP. In two cases the fracture was healed by that time and the implant could be removed, whereby the infection resolved within 3 months. The third fracture was still unstable when the infection occurred. The plate was replaced by an external fixator and with antibiotic therapy the tibia1 shaft showed bony union after 3 months and the osteitis appeared to be under control, allowing the external fixator to be removed. At follow up, the three patients had no problems resulting from their infection. The four cases of osteomyelitis of the open fracture series have already been discussed; no new case was observed later.

Open (N = 58)

implant

Implant -

6

(10.3%) 1 1

(1.7%) (1.7%)

6 DCP 1 Fix Ext 1 Fix Ext

Delayed union. Delayed union (absence of solid bony union at 4 months) was observed in 12 closed (6.8 per cent) and six Grade II and III open (10.3 per cent) tibia1 shaft fractures. Eight closed fractures (five DCP, three intramedullary nails) healed after application of a cast. Three further closed fractures, fixed with DCP, healed after reoperation with a new DCP. Fatigue fracture of the plate was observed in seven fractures (six open, one closed) always in association with a delay of bony union. Six of the seven broken plates were replaced by another plate, one by an intramedullary nail. All fractures subsequently went on to uneventful healing. Malunion. Shortening or axial deformity exceeding IO” was seen in only I closed tibia1 shaft fracture (1.7 per cent).

Bilat et al.: Osteosynthesis

355

of 245 tibia1 fractures

Table XI. Complications after implant removal (N= 229) Closed (N=174)

Re-fracture

2

Wound infection (superficial)

2

Open (N = 55)

lmplan t

(1.1%) (1.1%)

2 DCP 2DCP

The patient had multiple injuries including bilateral tibia1 shaft fractures (both Grade II open) which were initially stabilized with tubular external fixators and transformed 5 weeks later to DCP. Axial malalignment was not completely corrected at that time on one side. Once the other multiple lower limb fractures had healed, the patient underwent corrective osteotomy which healed without further delay. Deep venous thrombosis.

In four closed (2.3 per cent) and one open (1.7 per cent) tibia1 shaft fracture deep venous thrombosis was observed requiring anticoagulation. Our routine regimen against deep venous thrombosis consisted of low dose heparin in all patients starting preoperatively until hospital discharge.

Complications after implant (Table XI) At our late follow up, on average 79 months after injury, the implants had been removed in 229 of the 242 fractures (94.6 per cent). Six patients (2.5 per cent) with unilateral fractures had died of unrelated causes before implant removal. Seven patients (2.9 per cent) with unilateral fractures refused another operation. In these seven cases no further complications were observed. After implant removal the following complications occurred: Re-fracture. Grob and Magerl (1987) defined refracture ‘as a traumatic discontinuity of a bone segment in which a previous fracture had occurred. The first fracture, standing in causal connection with the refracture, had received adequate treatment and had been consolidated before the second trauma occurred. In our series a refracture occurred in two closed (1.1 per cent) and one Grade III open (1.7 per cent) tibia1 shaft fracture. However only one re-fracture (Figured) corresponds exactly to the definition of Grob and Magerl. In this case of a closed wedge fracture the implant, a DCP, was removed 19 months after osteosynthesis. Four months later this patient had a skiing accident again and sustained a similar wedge tibia1 shaft fracture at the same level as before. The re-fracture was treated as on the first occasion with a DCP and healed. In the second case of closed fracture the implant was removed ‘elsewhere’ without reason 9 months after the original plating. Four months later a re-fracture occurred without adequate trauma. This re-fracture was treated with a intramedullary nail. The third case, a Grade III open fracture after a motorcycle accident, initially had a 7cm segmental bone loss. At that time, in 1982, the recovered piece of the mid-third of the tibia was scrubbed and replaced to fill the gap, the whole bone being stabilized by a tubular external fixator. After healing of the soft tissues and addition of cancellous autografts from the anterior iliac crest, the external fixator was removed and the leg placed in a cast for 3 months. A fracture occurred through the necrotic segment 7 months later without significant trauma. An

1

(1.8%) -

intramedullary nail was then finally healed securely.

Implant 1 Fix Ext -

introduced

Total (N= 229) 3 2

(1.3%) (0.9%)

and the bone

Superficial infection. In two patients a superficial infection occurred 2 days after removal of a DCP. Both cases were treated successfully by irrigation of the wound with saline solution, elevation and immobilization.

Discussion In this series of closed and open tibia1 shaft fractures treated between 1980 and 1984, the majority of cases (80.4 per cent) were stabilized with the AO-DCP. Plating tibia1 shaft fractures at that time - 10 years ago - when the interlocked tibia1 nail was almost unheard of, appeared to be good treatment. The correct application of a plate combines the advantages of anatomical reduction with good fracture stability, allowing functional aftercare. The disadvantages of this demanding technique are the large exposure - more tissue damage - and the eccentric position of the fixation device. Plating of closed and Grade I open tibia1 shaft fractures produces a similarly low number of complications. In Grade II and III open fractures, that were primarily approached by plating, the number of complications was however considerably higher. Similar results were observed in earlier studies by Ri.iedi et al. (1975). According to Gershuni and Halma (1983) and Rommens and Schmit-Neuerberg (1987) plate fixation as a primary device should be used for closed, or Grade I open fractures and rarely in Grade II open fractures, a standpoint we fully share today. Closed fractures with extensive soft tissue contusion or Grade II and III open fractures that were initially stabilized with external fixation and plated secondarily, healed without complications. This treatment modality was also preferred for the emergency stabilization of tibia1 shaft fractures in multiply-injured patients. The only case of malunion of this series was a valgus malposition after external fixation, that could not be corrected completely by the secondary plating a few weeks after the accident. Blachut et al. (1990) presented similar sequential treatment with the intramedullary nail. Primary medullary nailing was performed in 28 closed and Grade I open fractures (11.4 per cent). At that time, the majority of the fractures were opened for reduction and then reamed. For fear of infection the intramedullary nail with reaming was never used in severe open fractures. The major complications of nailing were three delayed unions (12.5 per cent), which all healed after application of a below-knee cast. Four spiral fractures were stabilized by lag screws only. They all healed without complications. Not one clinically symptomatic compartment syndrome was observed in this whole series. The absence of any apparent compartment syndrome may be explained by (I) a low rate of high energy injury, (2) on average a short time between accident and surgery and (3) standard open fracture reduction and internal fixation in nearly all cases,

356

Injury: InternationalJournalof the Care of the Injured (1994) Vol. 25/No. 6

Figure 4. Refracture: u, Closed tibia1 shaft fracture from skiing. b, Primary stabilization with a T-hole DCP. c, 19 months after injury. Radiological situation after implant removal. d, 23 months after original injury. Closed re-fracture after new skiing injury. e, Again stabilization with an s-hole DCP. J 19 months after second injury. Radiological situation after implant removal.

Bilat et al.: Osteosynthesis of 245 tibia1fractures

357

d

which implies early and at least partial decompression of the compartments, especially that of the tibialis anterior muscle. The signs of infection in the open fracture series all appeared a few days after surgery and evolved into an osteomyelitis in spite of repeated and aggressive cleaning of the soft tissues. Except for one case, which healed after extensive cleaning, and immobilization in a below-knee cast, a number of additional procedures were required, such as sequestrectomy, lavage with antiseptic solutions, cancellous bone grafting, vascularized free flap and antibiotic therapy. In one instance of gas gangrene, a secondary ankle fusion was necessary to control infection. The implants in these cases were removed 4 to 14 months after initial osteosynthesis. No late occurrence of osteitis was observed after open fractures. This corresponds to the experience of Rittmann (1969). In contrast, all three cases of infection after open reduction and internal fixation of a closed fracture presented their first clinical symptoms late, more than 4 months after the accident and plating. In two patients the fractures appeared clinically and radiologically healed, so that the implants could be removed, which also resolved the infection. In the third, fracture, not yet completely healed, the DCP was replaced by an external fixator for 3 months. At follow up no further problems were recorded. In a total of 18 fractures we observed a delayed union with seven instances of fatigue fracture of the plate. In

Injury: InternationalJournalof the Care of the Injured (1994) Vol. 25/No. 6

358

retrospect, the delay in healing could be predicted in most instances because of inadequate initial fixation. This seems to prove that implant fatigue is practically always related to poor surgery or lack of aftercare and is not caused by material or manufacturing deficiencies. Furthermore these complications involved mostly fractures of the distal and middle third of the tibia, never the proximal third, which possibly reflects the poorer vascularity of the distal part of this bone (Schmit-Neuerburg, 1984; Menck et al., 1992). In the final outcome more patients had problems in the ankle than in the knee. This corresponds to the observation of Merchant and Dietz (1989) and Home et al. (1990). Since the introduction of the locked universal tibia1 nail and more recently with the new unreamed nail (UTN) the majority of tibia shaft fractures are nailed by closed technique, plating being reserved for metaphyseal fractures and other special indications. The new LC-DCP may be a better device respecting bone vascularity and thereby bone biology to a great extent. A refracture of the tibia was observed three times after implant removal. However only one case fulfilled the definition of Grob and Magerl (1987). In the two other cases fracture healing was incomplete at the time of implant removal. The latter must be correctly timed and carefully performed. With a high follow-up rate of more than 96 per cent, on average 6.5 years after surgery, this study gives a complete picture of success and complications. While the final outcome, judged by the functional result, was similar for both closed the open fractures with over 93 per cent of ‘excellent and good outcome’, the incidence of major complications varied considerably. According to Johner and Wruhs (1983) and Hegelmaier et al. (1990) there were more cases of deep infection/osteomyelitis as well as delayed unions with implant failure in the open fractures than in the closed series. This not only reflects the higher energy involved in open fractures with more soft tissue damage, but also the problem of plating, which requires good preoperative planning and a more useful surgical technique. While intramedullary without reaming -has

nailing

with interlocking-with

or

become the preferred technique for stabilizing diaphyseal fractures today, plating should not be dismissed altogether as there are still fractures especially involving the metaphysis and articular surfaces -which are still best fixed by plates, possibly the LC-DCP.

References Blachut P. A., Meek R. N., O’Brian P. J. (1990) External fixation and delayed intra-medullary nailing of open fractures of the tibia1 shaft. J. Bone joint Surg. [Am] 72A, 729. Gershuni D. H. and Halma G. (1983) The AO-external skeletal fixator in the treatment of severe tibia fractures. J. Truuma t 3,

986. Grob D. and Magerl F. (1987) Refrakturen. Unfallchirurgie 90,51. Hegelmaier C., Bierwirth P. and Schulz S. (1990) Sind Komplikationen nach Plattenosteosynthese am diaphysaren Unterschenkelschaft unvermeidlich? Unfallchirurgie 93,544. Home G., Iceton J., Twist J. and Malony R. (1990) Disability following fractures of the tibia1 shaft. Orthopedics 13, 423. Johner R. and Wruhs 0. (1983) Classification of tibia1 shaft fractures and correlation with results after rigid internal fixation. Clin. Orthop. 178,7. Menck J., Bertram Ch., Lierse W. and Wolter D. (1992) Das arterielle Versorgungsprinzip der Tibia und seine praktischen Konsequenzen. Langenbeck’s Arch. Chir. 377,229. Merchant T. C. and Dietz F. R. (1989) Long-term follow-up after fractures of the tibia1 and fibular shafts. 1. Bone Joint Surg [Am]. 71A, 599. Mi.iller M. E., Allgower M., Schneider R. and Willenegger H. (1977) Manualder Osteosynthese. AO- Technik. ZweiteAuj7age. Berlin, Heidelberg: Springer Verlag. Miiller M. E. (1990) The comprehensive classification of fractures of long bones. In: Miiller M. E., Allgower M., Schneider R. and Willenegger H. Manual of Internal Fixation. Techniques Recommended by the AO-ASIF Group. Third Edition, pp. 118-150. Springer Verlag, Berlin, Heidelberg, New York, Tokyo. Rittmann W. W., Pusterla C. and Matter P. (1969) Friih- und Spatinfektionen bei offenen Frakturen. Helueficu Chur. Acta

36,537. Rommens P. and Schmit-Neuerburg K. P. (1987) Ten years of experience with the operative management of tibia1 shaft fractures. J. Truuma 27, 917. Riiedi T., Webb J. K. and Allgower M. (1976) Experience with the dynamic compression plate in 418 recent fractures of the tibia1 shaft. Injury 7,252. Schmit-Neuerburg K. P. (1984) Die Plattenosteosynthese geschlossener Tibiaschaftfrakturen. Orthopiide 13,271.

Paper accepted

17 February

1994

Requesb for reprints should be addressed to: Christian Bilat MD, Department of Surgery, Kantonsspital, 7000 Chur, Switzerland.