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Primary medullary nailing of the tibia for fractures of the shaft in adults
84
INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY
Injury Oct. 1970
PRIMARY M E D U L L A R Y NAILING OF THE TIBIA FOR FRACTURES OF THE SHAFT IN ADULTS J. Z U C M A N and P. M A U R E R
Department of Orthopaedic and Reconstructive Surgery, H@ital Cochin, Paris
Nailing represents a particularly firm method of internal fixation for tibial fractures, allowing rapid resumption of weight-bearing. The avoidance ofopeningthe fracture has many advant a g e s - q u i c k e r union and much diminished risk of sepsis. The authors describe their technique of closed nailing without reaming. They have reviewed 356 cases; 207 were closed fractures of which 200 had good results. One hundred and forty-nine open fractures had 136 good results. One solitary case was amputated because of vascular complications. The infection rate was nil in closed fractures and 8"1 per cent in open fractures. All the infected cases healed secondarily after one or more operations. A solitary case of malunion has been encountered. The main indications for nailing are fractures of the lower third that are unstable, oblique, or short spiral or with a butterfly fragment; segmental fractures; fractures of the tibia associated with other injuries of the lower limb. Finally, indications for nailing could be extended to lower fractures, even to those 5 cm. from the ankle-joint. THE place of internal fixation in the management of tibial fractures is still a controversial topic. In England and in the U.S.A. most surgeons rely on conservative treatment (Sarmiento, 1967), but there are two papers by Alms (1962) and Per Edwards (1965) advocating medullary nailing. On the continent, by contrast, following the example of the Swiss school (Miiller, Allg6wer, and Willenegger, 1965) and of the French (d'Aubign6 and Franc, 1958), internal fixation has assumed increasing importance, and since 1958 Merle d'Aubign6 and Franc have been stressing the value of internal fixation in the treatment of open tibial fractures. In 1960 we started to use closed medullary nailing and we have gradually extended the indications for this technique so that we use it almost routinely in shaft fractures of the tibia that are appreciably displaced. In 1965 we published an initial series of 136 cases (Zucman and Maurer, 1965). Today our total number has risen to 356 cases treated and followed up. Several theoretical and experimental factors have led us to develop this technique. We will review the arguments in the discussion section of this paper, after first describing the operative
technique, which is somewhat different from that described by Ktintscher (1962), and analysing our results. OPERATIVE T E C H N I Q U E 1. Closed Fractures In those fractures where a direct approach is not indicated, closed nailing is undertaken. The patient is placed in the supine position, the hip is flexed to 70 °, and the knee is flexed to its maximum and held in this position by a horizontal bar. The leg now lies almost vertically and the fracture is thus easily reduced. There is no need for a tourniquet. The sole of the foot rests on a hard surface so that the lower fragment is not displaced by the blows of the hammer on the medullary nail (Fig. 1). A vertical incision, 5-7 cm. in length, is made just medial to the patellar tendon (Fig. 2). A small facet of the upper surface of the tibia just posterior to the tuberosity is exposed and its periosteum raised. It is possible to do this without opening the synovial membrane on either side. A guide wire is driven downwards through this facet and into the medullary canal (Fig. 3).. It is
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sometimes difficult to guide the wire into the distal medullary canal, but by manipulation success is usually achieved. Where this proves impossible, a direct surgical approach has to be made. A control radiograph confirms that the
/
Fig. 2.--Skin incision
- ~__
i'f~'z'~/j'j'a~:'
Fig. l.--Position of the patient on the operating table.
lacedoverthe guidewire, readyfor driving
~- ..... Awl
--~~ i~ t"~ ~V/J/
..~
Guidewire
i -~ Patldlar tend°nand fasciaretntcted
Fig. K--An awl preparing the entry point for the guide wire.
guide wire is in place and enables the required
length of nail to be estimated. The nail is placed on the guide wire (Fig. 4). A nail of 9 mm. in diameter is most often correct, but sometimes one of 10 or 11 mm. is required and on rare occasions one of 8 mm. At the beginning of our series we used a standard
Fig. 4.--The nail is driven down over the guide wire.
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INJURY" THE BRITISH JOURNAL OF ACCIDENT SURGERY
straight Ktintscher nail, but we have now adopted one with a forward bend at its upper end, which is easier to drive home and to extract. The guide wire is withdrawn as soon as the nail has engaged the first few centimetres of the distal fragment. The nail is driven on until its upper
obtained by making a large posterior decompressing incision which must be left open. In every case manoeuvres in the region of the fracture site should be reduced to a minimum. This technique has been described in greater detail in a previous paper (Deburge and Zueman,
L A
13
Fig. 5.--A, A simple spiral fracture in a man of 41 injured in a fall. 13, Appearance 1 year later. extremity is flush with the surface of the tibial plateau. Two or three vigorous blows on the sole of the foot result in good impaction of the fracture. After a control radiograph, the incision is closed and the operation is completed by a posterior plaster applied from toes to knee. This is replaced on the sixth day by a complete fullleg plaster. Weight-bearing is allowed when physical signs and radiographs show that union has occurred.
2. Open Fractures In these the same technique is employed. Before nailing the wound is carefully cleaned and sterilized. After nailing it is trimmed and the skin sutured. If the edges of the wound are contused they are excised and closure is obtained, extending the incision if necessary. Where there is any skin-loss, closure in front can be
1965). Image intensifiers have never been employed. In the great majority of cases two check radiographs are enough. Reaming was only used on two occasions. It will be shown later why we regard this as unnecessary. MATERIAL The above technique has been used for the treatment of 356 recent fractures of the shaft of the tibia in adults. By ' shaft' is meant the tibia from 5 cm. below the knee to 5 cm. above the ankle-joint. By ' recent ' is meant up to 30 days after injury and without previous treatment by any other form of internal fixation. By ' a d u l t ' is meant aged 16 or over. Three types of compounding were recognized (Cauchoix, Duparc, and Boulez, 1957):-i. A puncture wound or a wound at a distance from the fracture site; ii. A large wound exposing the fracture.site;
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Z U C M A N AND MAURER: PRIMARY MEDULLARY N A I L I N G
iii. Contused skin of doubtful viability, loss of skin substance, or a severe burn. The mean age of the patients was 43.8 years (43.3 for closed fractures, 44.5 for open fractures). Three patients were lost to follow-up and 13 patients (with 17 fractures) died before union was complete. Of the 356 cases remaining for analysis, 207 were closed fractures and 149 were open.
1. Closed Fractures Sixteen of the 207 were over 70 years of age and 7 were over 80. One hundred and twenty-six (61 per cent) were due to road accidents and of these, 70 fractures occurred in pedestrians. The latter group of patients was older than the majority, their mean age being 52 years.
a. Associated Injuries Seventy cases, amounting to 34 per cent, had associated injuries. These included 2 head injuries, 5 thoracic injuries, 10 pelvic fractures, 18 fractures of upper limbs, and 38 fractures of lower limbs, including 13 fractures of the femur on the same side, 10 fractures of the opposite leg, 4 fractures of the opposite femoral shaft, 2 fractures of the neck of the femur on same side, 2 fractures of the neck of the opposite femur, 4 bimalleolar fractures, and 3 fractures of the os calcis.
b. Fracture Type In 13 cases the fracture involved the lower quarter of the tibia (Fig. 5); in 31 cases (15 per cent) the fracture was comminuted, and in only 9 cases was the fibula intact. Nineteen of the fractures were segmental. In only 2 per cent of cases was the fracture irreducible and a direct surgical approach had to be made to introduce the guide wire into the distal fragment. Among these 6 cases 2 needed cerclage wires in addition to the nail to obtain fixation, and in 1 solitary case the medullary canal had to be reamed out.
2. Open Fractures One hundred and forty-nine open fractures were nailed and followed up until they were fully consolidated. Among the patients 12 were more than 70 and of these 3 were more than 80 years of age. None was younger than 16. Ten were between 16 and 20 years. One hundred and sixteen fractures (78 per cent) followed road traffic accidents. Of these, 56 patients (48 per cent) were pedestrians. Here again the unfortunate pedestrian was older than the average injured patient, whose mean age was 53 years.
87
a. Associated Injuries Fifty-seven patients (38 per cent) had associated injuries. Among these we found the following conditions: 2 severe bums, 24 head injuries, 5 thoracic injuries, 2 ruptures of the spleen, 1 vascular injury, 10 fractures of the pelvis, 19 fractures of the upper limbs, and 44 fractures of the lower limbs, including 11 fractures of the shaft of the femur on the same side, 14 fractures of the opposite tibia, 5 fractures of the opposite femoral shaft, 3 fractures of the neck of the femur of the same side, 2 fractures of the acetabulum, 5 fractures of the os calcis, and 4 bimalleolar fractures.
b. Fracture Type Seven fractures involved the lower quarter of the tibia; 37 (25 per cent) were comminuted (Fig. 6). In only 7 was the fibula intact, and 19 fractures were segmental (Fig. 7). In 10 cases advantage was taken of the presence of a skin wound to apply an additional internal fixation device to achieve greater rigidity; in 6 cases screws were used and in 4 cases cerclage wires. In 1 case the medullary canal was reamed out.
The 149 open fractures had skin wounds which, using the classification described above, could be grouped as follows : Type i : 82 cases (55 per cent) Type ii: 44 cases (30 per cent) Type iii: 23 cases (15 per cent). RF_~ULTS Deaths Of the 13 deaths, 8 occurred within a few hours of injury, 4 having severe brain injuries, 3 thoraco-abdominal injuries, and 1 severe burns. One, aged 83, with bilateral leg fractures, died at the eighth day. The remaining 4 died at home between the first and the third month.
Assessment of Results The remaining 356 results were assessed according to the following criteria (Table I ) : - -
Pseudarthroses These included all fractures that had not united after 3 months and which needed further operation to secure union. We thus agree with the definition of non-union defined by Nicoll (1964): 'Every fracture which, in the opinion of the surgeon, would not unite without an operation '. We added to this definition a delay of 3 months after the injury.
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3
~
•
A B Fig. 6.--A, Comminuted fracture with a skin wound of type ii in a woman of 21 who had been injured by
a tear-gas hand grenade. B, Appearance 8 months later.
-
15
K?;
C-
.-,-,"
A
B
Fig. 7.--A, Segmental fracture with a skin wound of 1 cm. (type i) in a man of 66 who had been driving
a motor-cycle. B, Appearance 9 months later.
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ZUCMAN AND MAURER" PRIMARY MEDULLARY NAILING
Sepsis Two distinct complications are considered under this heading: proven bacterial infection extending right down to the bone, and skin necrosis exposing the bone itself.
89
96"6 per cent of cases, typified by the one illustrated in Fig. 8. The mean time to weight-bearing without plaster cast was 13 weeks, but the mean time to produce radiological signs of union was 15 weeks. This is explained by the fact that a
Table/.--OVERALL RESULTSIN 356 NAILED FRACTURESOF THE TIBIA RESULT Primary union in good position Infection with primary union Infected pseudarthroses Aseptic pseudarthroses Malunion Amputation
CLOSEDFKACrUKES OPENFRACTURES (207) (149) 200 (96"6 per cent) 5 (2.4 per cent) 1 (0.5 per cent) 1 (0-5 per cent)
Ma[union We include under this title residual deformity of 10° or more of varus or of flexion, 15° of valgus or of backward bowing, 10° or more of internal rotation, 20° or more of external rotation.
1. Results in Closed Fractures In the 207 closed fractures, 200 healed in good position by primary intention and this comprised
A
136 (91-2 per cent) 7 (4.7 per cen0 5 (3.4 per cent) 1 (0.7 per cent)
certain number of patients began to bear weight without plaster before radiological signs of union had occurred. Among these were 10 patients in whom radiological union had certainly not occurred 6 months or more after nailing. Nevertbeless these patients all united finally without further intervention (Fig. 9). In 2 cases, however, unsatisfactory nailing required further operation.
B
Fig. 8.--A simple transverse fracture with a third butterfly fragment in a woman of 48 who had been knocked over by a car. A, The guide wire in position. B, Appearance 4 months later.
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I N J U R Y : THE BRITISH J O U R N A L OF A C C I D E N T S U R G E R Y
Complications a. Amputation: Only one amputation was necessary. It had to be done in a young man of 22 years who had sustained a fracture in the upper third of his tibia during a football match. The fracture was nailed as an emergency. Over the succeeding days he developed ischaemia. 80 7O 60 50 4O "d 3O 6 "7 20 10
ilNFIn
I-'I .r--'l r " l ,1"--[ 60 80 100 120 140 160 180 200 220 240260 280 300.320 Time (days)
Fig. 9.--Radiological union of 200 closed fractures. After 72 hours arteriography showed patent arteries but these were in spasm in the region of the fracture. In spite of two operations for exploration of the arteries and decompression, accompanied by very vigorous medical treatment, the spasm persisted and the leg was amputated after 1 month. b. Pseudarthrosis: Five cases were classified as pseudarthroses because union was not obtained until after a second operation. Two of these were segmental fractures. One occurred in a patient of 70 years; at 6 months the upper fracture site was not united and a graft screwed in place led to consolidation at the fourteenth month. The other patient was a man of 38 years and in his fracture a direct approach had been required to introduce the guide wire. At the third month, as the lower fragment had not united, it was grafted, and union was obtained at the sixth month. The third patient was a man of 32 who sustained a comminuted fracture. After nailing, an intermediate fragment was still badly displaced. At the third month this displacement suggested that non-union was developing, and the fragment was reduced and screwed and firm union was obtained at the sixth month. The two final cases recorded as pseudarthroses are more debatable. At the fourth month one
Iniury Oct. 1970
appeared to be clinically and radiologically united, but at the eleventh month, after another accident, he sustained a new spiral fracture in spite of the nail remaining in place. It appeared to be a replica of the first fracture. It was uncertain whether he had sustained a new fracture or whether his original fracture had not united. Simple immobilization in plaster led rapidly to final union. The other patient was a man of 34 years who sustained an oblique fracture which was nailed without trouble, but he was lost to follow-up after 7 weeks. We have since learnt that he had a further operation elsewhere at the sixth month. He wrote to us that he was ununited at this stage but we have no proof of this. c. Malunion: One case is classified as malunion. This was in a lady of 80 who had a very distal fracture. Incorrect nailing had allowed a varus position of 10° to remain and a backward angulation of 11°. The time to union was unaffected. Because of her age and other disorders no further treatment was undertaken. d. Sepsis: No case of sepsis was encountered, either superficial or deep, in the 207 closed fractures. e. Nail removah The nail was removed in about a third of our patients at the end of 1 year in order to avoid any trouble near its upper end. There is some doubt whether the tissues will tolerate a nail left in place indefinitely.
2. Results in Open Fractures Of 149 open fractures, 136 healed in good position by primary union. This comprises 91.2 per cent of cases (Fig. 10). These patients were able to bear weight without plaster at the end of 15 weeks on the average. The time before the appearance of radiological signs of union, however, averaged 18 weeks. Here again many patients were able to bear weight without any radiological signs of uniting callus, sometimes after several months. Among them were 21 patients in whom radiological union was not established for 6 months or more after nailing. Nevertheless these fractures were in almost every case finally united without further operation (Fig. 11). Among these 136 cases, however, 6 required other operations. I n 4 cases a skin-graft was necessary (3 at one month and 1 at the second month). All these cases healed straightforwardly without infection. In 2 cases further impaction of the nail was necessary as the upper end was protruding too far. Both went on to uneventful union.
Volume
2
ZUCMAN
Number 2
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PRIMARY
Complications a. Simple infection: Sepsis was classified as simple in 7 cases because it did not delay union. In 4 of these a small sinus occurred which healed up after removal of the nail at the thirteenth, eighth, seventh, and fifth month respectively.
MEDULLARY
91
NAILING
There were 3 sequestrectomies, 3 skin-grafts, 5 bone-grafts, and 5 other operations. In 2 cases the nail had to be removed before union. All united. In 1 a sinus persisted, and this case had also developed septic arthritis which led to an ankylosed knee.
i/
i
!ii!i
1-22 -.i, .,%, .?.
C' ..
':~.
rL
/
A A
B
Fig. 10.--A, Transverse fracture with a puncture wound (type i) in a man of 69 who had been knocked down by a car. B, Appearance 6 months later.
0t "6 2O
60 80 100 120 140 160 180 200 220240 260 280 300 320 Time (days)
Fig. 11.--R.adiological union of 136 open fractures. In 2 cases a sinus persisted for 1 year and 18 months respectively after removal of the nail, in spite of curettage and sequestrectomy. One case is still under treatment with radiological signs of union, but the nail has not yet been removed. The mean time to radiological union among these 7 cases of infection was 21 weeks. b. Infected non-union: Five cases developed infected non-union and these required altogether 16 operations (in addition to the primary nailing).
c. Aseptic pseudarthrosis: One case was classified under this title. It occurred in a man of 46 who sustained a very comminuted fracture with gross skin damage of type iii. Nailing was reinforced by three cerclage wires. No infection occurred, but after 9 months the fracture had not united and a zone of rarefaction had appeared around one of the cerclage wires. A tibiofibular bone-graft was applied and this led to firm union in 4 months. d. Amputation: No secondary amputation was urtdertaken in any of the 149 open fractures. e. Malunion: There was no case of malunion. DISCUSSION Medullary nailing provides one of the strongest forms of internal fixation and in fact in nearly 400 tibial fractures we have not had one broken or bent nail, even among the 8-ram. diameter nails. Disagreeing with other authors (Ki~ntscher, 1962; Schvingt, Weill, and Berger, 1967), we
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INJURY : THE BRITISH JOURNAL OF ACCIDENT SURGERY
think that reaming of the tibia is not necessary, for the following reasons: an 8- or 9-mm. nail is solid enough; usually a thicker nail does not provide a better blockage of rotational mobility in the fracture site; reaming increases the risk of infection. W e have shown that periosteai vessels play a greater part than medullary ones in vascularizing callus (Maurer, Evrard, and van Houtte, 1963; Maurer, Zucman, and Lewalle, 1965). Medullary nailing has the advantage over other methods of internal fixation in that the fracture site is not disturbed so that the retardation of callus formation that follows open operation is less likely
30
A //
Closedfractures (200)
c
~'
20
I0
. . . . . . . . . . ""7"-~ . 60 80 100 120 140 160 180 200 220 240 260 280.300 320 Time (days)
Fig. 12.--Radiologica] union of tibial fractures. to occur. The retardation of the callus formation by the opening of the focus appears clearly in Fig. 12, where delays for union in closed and open fractures are compared. The risk of infection is less than with other methods of internal fixation. Control of rotation deformity still presents some problems however. In open fractures we have had an overall infection rate of 8.1 per cent. The size of the implant does not seem to affect the severity of the infection. In fact, in more than half the cases (in 7 out of 12) only mild infection arose, and this did not interfere with union. The 5 other cases, which were infected pseudaxthroses, were certainly more serious, but it was the severity of the
Injury Oct. 1970
primary injuries which led to these complications. In 1 case osteitis was complicated by septic arthritis of the knee; in no case have we encountered an infection of the whole diaphysis, and all the septic pseudarthroses finally united after further operation. In conclusion, closed medullary nailing of the tibia seems to us to be a method which in open fractures allows union to occur over a period in the large majority, without entailing infection at a high rate or of any great severity.
REFERENCES ALMS, M. (1962), ' Medullary Nailing for Fracture of the Shaft of the Tibia ', J. Bone Jt Surg., 44B, 328. D'AumGI'~, M. R., and FRANC, C. (1958), 'Traitemerit des Fractures Ouvertes de Jambe ', Mdm. Acad. Chir., 83, 814. CAUCHOlX, J., DUVARC, J., and BOULEZ, P. (1957), 'Traitement des Fractures Ouvertes de Jambe ', Ibid., 83, 810. DEBURGE, H., and ZUCMAN,J. (1965), ' Technique de l'Enclouage Percutan6 du Tibia sans Al6.sage ', Presse m~d., 73, 2109. EDWARDS, P. (1965), ' The Effect of Crush Injury to the Skin on Healing of Fracture of the Shaft of the Tibia in Dogs ', Acta orthop, scand., 36, 89. KDNTSCHER, G. (1962), Die Marknagelung. Berlin: Springer. LEMAIRE,R. (1969), ' L'Enclouage M6dullaire darts le Traitement des Fractures Diaphysaires R6centes du Tibia ', Aeta chir. belg., 68, 31. MAURER, P., EVRARD, J., and VAN HOUTTE, X. (1963), ' Contribution a l'i~tude de la Consolidation Osseuse. Etude des R6actions Vasculaires au Niveau et autour du Foyer de Fracture ', Revue Chir. orthop, rdpat'. Appar. moteur, 49, 689. - - - - ZUCMAN, J., and LEWALLE, J. (1965), ' R61e de
la Vascularisation P~rifacturaire et Centrom~dullaire dans l'Ost6ogc!n~se ', Ibid., 51, 229. MOLLER, M. E., ALLGOWER, M., and WILLENEGGER, H. (1965), Technique of Internal Fixation of Fractures. Berlin: Springer. NICOLL, E. A. (1964), ' Fractures of the Tibial Shaft ', J. Bone Jt Surg., 46B, 373. SARMIENTO, A. (1967), ' A Functional Below-knee Cast for Tibial Fractures ', Ibid., 49A, 855. SCHVZNGT, E., WEILL, D., and BERGER, J. (1967), ' Fractures du Tibia trait6es par Enclouage ~. Foyer Ferm6 scion la M6thode de Kfintscher ', Presse todd., 75, 1814. ZUCMAN, J., and MAURER, P. (1965), ' L'Enclouage Centro-m6dullaire du Tibia dam le Traitement des Fractures Diaphysaires de Jambe R6centes de l'Adulte', Revue Chir. orthop, rdpar. Appar. moteur, 51, 475.
Requests for reprints shouM be addressed to:--Dr. J. Zucman, Pavilion Oilier, H6pital Cochin, 27 rue du Faubourg Saint Jacques, Paris 14eme, France.
INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY
Injury Oct. 1970
PRIMARY M E D U L L A R Y NAILING OF THE TIBIA FOR FRACTURES OF THE SHAFT IN ADULTS J. Z U C M A N and P. M A U R E R
Department of Orthopaedic and Reconstructive Surgery, H@ital Cochin, Paris
Nailing represents a particularly firm method of internal fixation for tibial fractures, allowing rapid resumption of weight-bearing. The avoidance ofopeningthe fracture has many advant a g e s - q u i c k e r union and much diminished risk of sepsis. The authors describe their technique of closed nailing without reaming. They have reviewed 356 cases; 207 were closed fractures of which 200 had good results. One hundred and forty-nine open fractures had 136 good results. One solitary case was amputated because of vascular complications. The infection rate was nil in closed fractures and 8"1 per cent in open fractures. All the infected cases healed secondarily after one or more operations. A solitary case of malunion has been encountered. The main indications for nailing are fractures of the lower third that are unstable, oblique, or short spiral or with a butterfly fragment; segmental fractures; fractures of the tibia associated with other injuries of the lower limb. Finally, indications for nailing could be extended to lower fractures, even to those 5 cm. from the ankle-joint. THE place of internal fixation in the management of tibial fractures is still a controversial topic. In England and in the U.S.A. most surgeons rely on conservative treatment (Sarmiento, 1967), but there are two papers by Alms (1962) and Per Edwards (1965) advocating medullary nailing. On the continent, by contrast, following the example of the Swiss school (Miiller, Allg6wer, and Willenegger, 1965) and of the French (d'Aubign6 and Franc, 1958), internal fixation has assumed increasing importance, and since 1958 Merle d'Aubign6 and Franc have been stressing the value of internal fixation in the treatment of open tibial fractures. In 1960 we started to use closed medullary nailing and we have gradually extended the indications for this technique so that we use it almost routinely in shaft fractures of the tibia that are appreciably displaced. In 1965 we published an initial series of 136 cases (Zucman and Maurer, 1965). Today our total number has risen to 356 cases treated and followed up. Several theoretical and experimental factors have led us to develop this technique. We will review the arguments in the discussion section of this paper, after first describing the operative
technique, which is somewhat different from that described by Ktintscher (1962), and analysing our results. OPERATIVE T E C H N I Q U E 1. Closed Fractures In those fractures where a direct approach is not indicated, closed nailing is undertaken. The patient is placed in the supine position, the hip is flexed to 70 °, and the knee is flexed to its maximum and held in this position by a horizontal bar. The leg now lies almost vertically and the fracture is thus easily reduced. There is no need for a tourniquet. The sole of the foot rests on a hard surface so that the lower fragment is not displaced by the blows of the hammer on the medullary nail (Fig. 1). A vertical incision, 5-7 cm. in length, is made just medial to the patellar tendon (Fig. 2). A small facet of the upper surface of the tibia just posterior to the tuberosity is exposed and its periosteum raised. It is possible to do this without opening the synovial membrane on either side. A guide wire is driven downwards through this facet and into the medullary canal (Fig. 3).. It is
Volume 2 Number 2
ZUCMAN AND MAURER: PRIMARY MEDULLARY NAILING
85
sometimes difficult to guide the wire into the distal medullary canal, but by manipulation success is usually achieved. Where this proves impossible, a direct surgical approach has to be made. A control radiograph confirms that the
/
Fig. 2.--Skin incision
- ~__
i'f~'z'~/j'j'a~:'
Fig. l.--Position of the patient on the operating table.
lacedoverthe guidewire, readyfor driving
~- ..... Awl
--~~ i~ t"~ ~V/J/
..~
Guidewire
i -~ Patldlar tend°nand fasciaretntcted
Fig. K--An awl preparing the entry point for the guide wire.
guide wire is in place and enables the required
length of nail to be estimated. The nail is placed on the guide wire (Fig. 4). A nail of 9 mm. in diameter is most often correct, but sometimes one of 10 or 11 mm. is required and on rare occasions one of 8 mm. At the beginning of our series we used a standard
Fig. 4.--The nail is driven down over the guide wire.
86
Injury Oct. 1970
INJURY" THE BRITISH JOURNAL OF ACCIDENT SURGERY
straight Ktintscher nail, but we have now adopted one with a forward bend at its upper end, which is easier to drive home and to extract. The guide wire is withdrawn as soon as the nail has engaged the first few centimetres of the distal fragment. The nail is driven on until its upper
obtained by making a large posterior decompressing incision which must be left open. In every case manoeuvres in the region of the fracture site should be reduced to a minimum. This technique has been described in greater detail in a previous paper (Deburge and Zueman,
L A
13
Fig. 5.--A, A simple spiral fracture in a man of 41 injured in a fall. 13, Appearance 1 year later. extremity is flush with the surface of the tibial plateau. Two or three vigorous blows on the sole of the foot result in good impaction of the fracture. After a control radiograph, the incision is closed and the operation is completed by a posterior plaster applied from toes to knee. This is replaced on the sixth day by a complete fullleg plaster. Weight-bearing is allowed when physical signs and radiographs show that union has occurred.
2. Open Fractures In these the same technique is employed. Before nailing the wound is carefully cleaned and sterilized. After nailing it is trimmed and the skin sutured. If the edges of the wound are contused they are excised and closure is obtained, extending the incision if necessary. Where there is any skin-loss, closure in front can be
1965). Image intensifiers have never been employed. In the great majority of cases two check radiographs are enough. Reaming was only used on two occasions. It will be shown later why we regard this as unnecessary. MATERIAL The above technique has been used for the treatment of 356 recent fractures of the shaft of the tibia in adults. By ' shaft' is meant the tibia from 5 cm. below the knee to 5 cm. above the ankle-joint. By ' recent ' is meant up to 30 days after injury and without previous treatment by any other form of internal fixation. By ' a d u l t ' is meant aged 16 or over. Three types of compounding were recognized (Cauchoix, Duparc, and Boulez, 1957):-i. A puncture wound or a wound at a distance from the fracture site; ii. A large wound exposing the fracture.site;
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Z U C M A N AND MAURER: PRIMARY MEDULLARY N A I L I N G
iii. Contused skin of doubtful viability, loss of skin substance, or a severe burn. The mean age of the patients was 43.8 years (43.3 for closed fractures, 44.5 for open fractures). Three patients were lost to follow-up and 13 patients (with 17 fractures) died before union was complete. Of the 356 cases remaining for analysis, 207 were closed fractures and 149 were open.
1. Closed Fractures Sixteen of the 207 were over 70 years of age and 7 were over 80. One hundred and twenty-six (61 per cent) were due to road accidents and of these, 70 fractures occurred in pedestrians. The latter group of patients was older than the majority, their mean age being 52 years.
a. Associated Injuries Seventy cases, amounting to 34 per cent, had associated injuries. These included 2 head injuries, 5 thoracic injuries, 10 pelvic fractures, 18 fractures of upper limbs, and 38 fractures of lower limbs, including 13 fractures of the femur on the same side, 10 fractures of the opposite leg, 4 fractures of the opposite femoral shaft, 2 fractures of the neck of the femur on same side, 2 fractures of the neck of the opposite femur, 4 bimalleolar fractures, and 3 fractures of the os calcis.
b. Fracture Type In 13 cases the fracture involved the lower quarter of the tibia (Fig. 5); in 31 cases (15 per cent) the fracture was comminuted, and in only 9 cases was the fibula intact. Nineteen of the fractures were segmental. In only 2 per cent of cases was the fracture irreducible and a direct surgical approach had to be made to introduce the guide wire into the distal fragment. Among these 6 cases 2 needed cerclage wires in addition to the nail to obtain fixation, and in 1 solitary case the medullary canal had to be reamed out.
2. Open Fractures One hundred and forty-nine open fractures were nailed and followed up until they were fully consolidated. Among the patients 12 were more than 70 and of these 3 were more than 80 years of age. None was younger than 16. Ten were between 16 and 20 years. One hundred and sixteen fractures (78 per cent) followed road traffic accidents. Of these, 56 patients (48 per cent) were pedestrians. Here again the unfortunate pedestrian was older than the average injured patient, whose mean age was 53 years.
87
a. Associated Injuries Fifty-seven patients (38 per cent) had associated injuries. Among these we found the following conditions: 2 severe bums, 24 head injuries, 5 thoracic injuries, 2 ruptures of the spleen, 1 vascular injury, 10 fractures of the pelvis, 19 fractures of the upper limbs, and 44 fractures of the lower limbs, including 11 fractures of the shaft of the femur on the same side, 14 fractures of the opposite tibia, 5 fractures of the opposite femoral shaft, 3 fractures of the neck of the femur of the same side, 2 fractures of the acetabulum, 5 fractures of the os calcis, and 4 bimalleolar fractures.
b. Fracture Type Seven fractures involved the lower quarter of the tibia; 37 (25 per cent) were comminuted (Fig. 6). In only 7 was the fibula intact, and 19 fractures were segmental (Fig. 7). In 10 cases advantage was taken of the presence of a skin wound to apply an additional internal fixation device to achieve greater rigidity; in 6 cases screws were used and in 4 cases cerclage wires. In 1 case the medullary canal was reamed out.
The 149 open fractures had skin wounds which, using the classification described above, could be grouped as follows : Type i : 82 cases (55 per cent) Type ii: 44 cases (30 per cent) Type iii: 23 cases (15 per cent). RF_~ULTS Deaths Of the 13 deaths, 8 occurred within a few hours of injury, 4 having severe brain injuries, 3 thoraco-abdominal injuries, and 1 severe burns. One, aged 83, with bilateral leg fractures, died at the eighth day. The remaining 4 died at home between the first and the third month.
Assessment of Results The remaining 356 results were assessed according to the following criteria (Table I ) : - -
Pseudarthroses These included all fractures that had not united after 3 months and which needed further operation to secure union. We thus agree with the definition of non-union defined by Nicoll (1964): 'Every fracture which, in the opinion of the surgeon, would not unite without an operation '. We added to this definition a delay of 3 months after the injury.
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3
~
•
A B Fig. 6.--A, Comminuted fracture with a skin wound of type ii in a woman of 21 who had been injured by
a tear-gas hand grenade. B, Appearance 8 months later.
-
15
K?;
C-
.-,-,"
A
B
Fig. 7.--A, Segmental fracture with a skin wound of 1 cm. (type i) in a man of 66 who had been driving
a motor-cycle. B, Appearance 9 months later.
Volume 2 Number 2
ZUCMAN AND MAURER" PRIMARY MEDULLARY NAILING
Sepsis Two distinct complications are considered under this heading: proven bacterial infection extending right down to the bone, and skin necrosis exposing the bone itself.
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96"6 per cent of cases, typified by the one illustrated in Fig. 8. The mean time to weight-bearing without plaster cast was 13 weeks, but the mean time to produce radiological signs of union was 15 weeks. This is explained by the fact that a
Table/.--OVERALL RESULTSIN 356 NAILED FRACTURESOF THE TIBIA RESULT Primary union in good position Infection with primary union Infected pseudarthroses Aseptic pseudarthroses Malunion Amputation
CLOSEDFKACrUKES OPENFRACTURES (207) (149) 200 (96"6 per cent) 5 (2.4 per cent) 1 (0.5 per cent) 1 (0-5 per cent)
Ma[union We include under this title residual deformity of 10° or more of varus or of flexion, 15° of valgus or of backward bowing, 10° or more of internal rotation, 20° or more of external rotation.
1. Results in Closed Fractures In the 207 closed fractures, 200 healed in good position by primary intention and this comprised
A
136 (91-2 per cent) 7 (4.7 per cen0 5 (3.4 per cent) 1 (0.7 per cent)
certain number of patients began to bear weight without plaster before radiological signs of union had occurred. Among these were 10 patients in whom radiological union had certainly not occurred 6 months or more after nailing. Nevertbeless these patients all united finally without further intervention (Fig. 9). In 2 cases, however, unsatisfactory nailing required further operation.
B
Fig. 8.--A simple transverse fracture with a third butterfly fragment in a woman of 48 who had been knocked over by a car. A, The guide wire in position. B, Appearance 4 months later.
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I N J U R Y : THE BRITISH J O U R N A L OF A C C I D E N T S U R G E R Y
Complications a. Amputation: Only one amputation was necessary. It had to be done in a young man of 22 years who had sustained a fracture in the upper third of his tibia during a football match. The fracture was nailed as an emergency. Over the succeeding days he developed ischaemia. 80 7O 60 50 4O "d 3O 6 "7 20 10
ilNFIn
I-'I .r--'l r " l ,1"--[ 60 80 100 120 140 160 180 200 220 240260 280 300.320 Time (days)
Fig. 9.--Radiological union of 200 closed fractures. After 72 hours arteriography showed patent arteries but these were in spasm in the region of the fracture. In spite of two operations for exploration of the arteries and decompression, accompanied by very vigorous medical treatment, the spasm persisted and the leg was amputated after 1 month. b. Pseudarthrosis: Five cases were classified as pseudarthroses because union was not obtained until after a second operation. Two of these were segmental fractures. One occurred in a patient of 70 years; at 6 months the upper fracture site was not united and a graft screwed in place led to consolidation at the fourteenth month. The other patient was a man of 38 years and in his fracture a direct approach had been required to introduce the guide wire. At the third month, as the lower fragment had not united, it was grafted, and union was obtained at the sixth month. The third patient was a man of 32 who sustained a comminuted fracture. After nailing, an intermediate fragment was still badly displaced. At the third month this displacement suggested that non-union was developing, and the fragment was reduced and screwed and firm union was obtained at the sixth month. The two final cases recorded as pseudarthroses are more debatable. At the fourth month one
Iniury Oct. 1970
appeared to be clinically and radiologically united, but at the eleventh month, after another accident, he sustained a new spiral fracture in spite of the nail remaining in place. It appeared to be a replica of the first fracture. It was uncertain whether he had sustained a new fracture or whether his original fracture had not united. Simple immobilization in plaster led rapidly to final union. The other patient was a man of 34 years who sustained an oblique fracture which was nailed without trouble, but he was lost to follow-up after 7 weeks. We have since learnt that he had a further operation elsewhere at the sixth month. He wrote to us that he was ununited at this stage but we have no proof of this. c. Malunion: One case is classified as malunion. This was in a lady of 80 who had a very distal fracture. Incorrect nailing had allowed a varus position of 10° to remain and a backward angulation of 11°. The time to union was unaffected. Because of her age and other disorders no further treatment was undertaken. d. Sepsis: No case of sepsis was encountered, either superficial or deep, in the 207 closed fractures. e. Nail removah The nail was removed in about a third of our patients at the end of 1 year in order to avoid any trouble near its upper end. There is some doubt whether the tissues will tolerate a nail left in place indefinitely.
2. Results in Open Fractures Of 149 open fractures, 136 healed in good position by primary union. This comprises 91.2 per cent of cases (Fig. 10). These patients were able to bear weight without plaster at the end of 15 weeks on the average. The time before the appearance of radiological signs of union, however, averaged 18 weeks. Here again many patients were able to bear weight without any radiological signs of uniting callus, sometimes after several months. Among them were 21 patients in whom radiological union was not established for 6 months or more after nailing. Nevertheless these fractures were in almost every case finally united without further operation (Fig. 11). Among these 136 cases, however, 6 required other operations. I n 4 cases a skin-graft was necessary (3 at one month and 1 at the second month). All these cases healed straightforwardly without infection. In 2 cases further impaction of the nail was necessary as the upper end was protruding too far. Both went on to uneventful union.
Volume
2
ZUCMAN
Number 2
AND
MAURER"
PRIMARY
Complications a. Simple infection: Sepsis was classified as simple in 7 cases because it did not delay union. In 4 of these a small sinus occurred which healed up after removal of the nail at the thirteenth, eighth, seventh, and fifth month respectively.
MEDULLARY
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NAILING
There were 3 sequestrectomies, 3 skin-grafts, 5 bone-grafts, and 5 other operations. In 2 cases the nail had to be removed before union. All united. In 1 a sinus persisted, and this case had also developed septic arthritis which led to an ankylosed knee.
i/
i
!ii!i
1-22 -.i, .,%, .?.
C' ..
':~.
rL
/
A A
B
Fig. 10.--A, Transverse fracture with a puncture wound (type i) in a man of 69 who had been knocked down by a car. B, Appearance 6 months later.
0t "6 2O
60 80 100 120 140 160 180 200 220240 260 280 300 320 Time (days)
Fig. 11.--R.adiological union of 136 open fractures. In 2 cases a sinus persisted for 1 year and 18 months respectively after removal of the nail, in spite of curettage and sequestrectomy. One case is still under treatment with radiological signs of union, but the nail has not yet been removed. The mean time to radiological union among these 7 cases of infection was 21 weeks. b. Infected non-union: Five cases developed infected non-union and these required altogether 16 operations (in addition to the primary nailing).
c. Aseptic pseudarthrosis: One case was classified under this title. It occurred in a man of 46 who sustained a very comminuted fracture with gross skin damage of type iii. Nailing was reinforced by three cerclage wires. No infection occurred, but after 9 months the fracture had not united and a zone of rarefaction had appeared around one of the cerclage wires. A tibiofibular bone-graft was applied and this led to firm union in 4 months. d. Amputation: No secondary amputation was urtdertaken in any of the 149 open fractures. e. Malunion: There was no case of malunion. DISCUSSION Medullary nailing provides one of the strongest forms of internal fixation and in fact in nearly 400 tibial fractures we have not had one broken or bent nail, even among the 8-ram. diameter nails. Disagreeing with other authors (Ki~ntscher, 1962; Schvingt, Weill, and Berger, 1967), we
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think that reaming of the tibia is not necessary, for the following reasons: an 8- or 9-mm. nail is solid enough; usually a thicker nail does not provide a better blockage of rotational mobility in the fracture site; reaming increases the risk of infection. W e have shown that periosteai vessels play a greater part than medullary ones in vascularizing callus (Maurer, Evrard, and van Houtte, 1963; Maurer, Zucman, and Lewalle, 1965). Medullary nailing has the advantage over other methods of internal fixation in that the fracture site is not disturbed so that the retardation of callus formation that follows open operation is less likely
30
A //
Closedfractures (200)
c
~'
20
I0
. . . . . . . . . . ""7"-~ . 60 80 100 120 140 160 180 200 220 240 260 280.300 320 Time (days)
Fig. 12.--Radiologica] union of tibial fractures. to occur. The retardation of the callus formation by the opening of the focus appears clearly in Fig. 12, where delays for union in closed and open fractures are compared. The risk of infection is less than with other methods of internal fixation. Control of rotation deformity still presents some problems however. In open fractures we have had an overall infection rate of 8.1 per cent. The size of the implant does not seem to affect the severity of the infection. In fact, in more than half the cases (in 7 out of 12) only mild infection arose, and this did not interfere with union. The 5 other cases, which were infected pseudaxthroses, were certainly more serious, but it was the severity of the
Injury Oct. 1970
primary injuries which led to these complications. In 1 case osteitis was complicated by septic arthritis of the knee; in no case have we encountered an infection of the whole diaphysis, and all the septic pseudarthroses finally united after further operation. In conclusion, closed medullary nailing of the tibia seems to us to be a method which in open fractures allows union to occur over a period in the large majority, without entailing infection at a high rate or of any great severity.
REFERENCES ALMS, M. (1962), ' Medullary Nailing for Fracture of the Shaft of the Tibia ', J. Bone Jt Surg., 44B, 328. D'AumGI'~, M. R., and FRANC, C. (1958), 'Traitemerit des Fractures Ouvertes de Jambe ', Mdm. Acad. Chir., 83, 814. CAUCHOlX, J., DUVARC, J., and BOULEZ, P. (1957), 'Traitement des Fractures Ouvertes de Jambe ', Ibid., 83, 810. DEBURGE, H., and ZUCMAN,J. (1965), ' Technique de l'Enclouage Percutan6 du Tibia sans Al6.sage ', Presse m~d., 73, 2109. EDWARDS, P. (1965), ' The Effect of Crush Injury to the Skin on Healing of Fracture of the Shaft of the Tibia in Dogs ', Acta orthop, scand., 36, 89. KDNTSCHER, G. (1962), Die Marknagelung. Berlin: Springer. LEMAIRE,R. (1969), ' L'Enclouage M6dullaire darts le Traitement des Fractures Diaphysaires R6centes du Tibia ', Aeta chir. belg., 68, 31. MAURER, P., EVRARD, J., and VAN HOUTTE, X. (1963), ' Contribution a l'i~tude de la Consolidation Osseuse. Etude des R6actions Vasculaires au Niveau et autour du Foyer de Fracture ', Revue Chir. orthop, rdpat'. Appar. moteur, 49, 689. - - - - ZUCMAN, J., and LEWALLE, J. (1965), ' R61e de
la Vascularisation P~rifacturaire et Centrom~dullaire dans l'Ost6ogc!n~se ', Ibid., 51, 229. MOLLER, M. E., ALLGOWER, M., and WILLENEGGER, H. (1965), Technique of Internal Fixation of Fractures. Berlin: Springer. NICOLL, E. A. (1964), ' Fractures of the Tibial Shaft ', J. Bone Jt Surg., 46B, 373. SARMIENTO, A. (1967), ' A Functional Below-knee Cast for Tibial Fractures ', Ibid., 49A, 855. SCHVZNGT, E., WEILL, D., and BERGER, J. (1967), ' Fractures du Tibia trait6es par Enclouage ~. Foyer Ferm6 scion la M6thode de Kfintscher ', Presse todd., 75, 1814. ZUCMAN, J., and MAURER, P. (1965), ' L'Enclouage Centro-m6dullaire du Tibia dam le Traitement des Fractures Diaphysaires de Jambe R6centes de l'Adulte', Revue Chir. orthop, rdpar. Appar. moteur, 51, 475.
Requests for reprints shouM be addressed to:--Dr. J. Zucman, Pavilion Oilier, H6pital Cochin, 27 rue du Faubourg Saint Jacques, Paris 14eme, France.