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Tibial fractures treated according to the AO∗ method
Injury, 4, 213-220
213
Tibia1 fractures treated the AO* method
according
to
K. Solheim Surgical Department Ill, UlJevBl Hospital, Norway
A series of the first 100 tibia1 fractures treated in a general surgical department according to the A0 method is presented. One case of non-union, due to technical failure was encountered. Four cases of deep infection occurred. Two of these subsided after removal of the metal. Re-fracture was a problem occurring for different reasons in 6 patients. Most of the fractures were difficult ones and it is concluded that the A0 method is a definite advance in the operative treatment of tibia1 fractures. THE treatment of adult tibia1 shaft fractures is a much disputed topic. It is not the purpose of this paper to go into detail in this discussion but to review the results of operative treatment according to the A0 method in a general surgical department. This method, based on the experimental and clinical work of many workers and
introduced 10 years ago, seems in expert hands to yield admirable results (Mi.iller, Allgower, and Willenegger, 1965) and it is understandable that the A0 implants, technique, and principles have achieved widespread use. We have used them since 1967.
THE
SERIES
From 1967 to 1970 inclusive, 98 patients with 100 tibia1 shaft fractures have been treated by the A0 technique. Two patients had bilateral fractures. The case histories have been reviewed and the patients followed up clinically and radiologically from 6 months to e years. Only 10 patients were observed for less than a year. Age and sex distribution are shown in Fig. 1. The causes of injury are shown in Table I. More than half of the patients were injured in
Females
Males IIIII
10-19
20-29
30-39
40-49
50-59
60-69
70-79
80-89 Age
Fig. I.-Tibia1
shaft fractures.
*Arbeitsgemeinschaft
Distribution
fiir Osteosynthesefragen.
by age and sex.
groups
214
Injury:
A
the British
Journal
of Accident
Surgery
Vol. ~/NO. 3
C
B
Male, aged 18. Skiing accident. Spiral fracture in lower third. Traction for 9 days. Closed reduction unsuccessful. B, Open reduction and internal fixation with three lag screws. Plaster for 10 weeks. Full weight-bearing at 14 weeks. C, Seven months after the accident. Sound union and normal function.
Fig. 2.-A,
A
B
C
Fig. 3.-A, Female, aged 50. Traffic accident. Cerebral concussion, rib fractures, subtrochanteric femoral fracture, ankle fracture, and comminuted tibia1 fracture with butterfly fragment. Traction for 12 days. B, At one operation, rigid internal fixation of all fractures, using an angled blade-plate nail for the femoral fracture, two lag screws and a tension-band plate for the tibia1 fracture, and malleolar screws for the ankle fracture. The tibia1 fracture would have been treated conservatively if this had been the only injury. No plaster was used. C, Sound union and normal function one year later.
Solheim : Tibia1 Fractures
215
traffic accidents, in which comminuted fractures were common (in 46 patients) and often caused by direct violence (in 43 patients). The fractures were open in 19 cases and 3 patients had segmental fractures. Eighteen patients had severe associated injuries (Table II).
Table///.-Circumstances undertaken
TREATMENT Close attention was paid to the soft tissues, especially to the skin overlying the fracture. This is why in only 37 fractures was internal Tab/e /.-Causes
of the injury
Cause
No. of patients
Traffic accidents Accidents at work Accidents at sport and games Falls on the same level indoors Falls on the same level outdoors
55 5 14 5 19
Tota I
98
Tab/e //.-Severe in 18 patients
them and fixing them to the bone in the special way recommended by the A0 group, or used as neutralization plates. Figs. 2-8 illustrate some of the applications. The longest plates were used in the segmental and comminuted fractures. Our
associated injuries
in which A0 treatmentwas
Treatment
No. of fractures
Primary internal fixation Delayed primary fixation
37 50
Secondary internal fixation
Tab/e /K--Types
13
Notes
Unsuccessful reduction, 7. Priority for treatment of associated injuries, poor skin, etc., 43. Within 2 weeks, 42; within 2-4 weeks, 8. At 3-12 months. Because of delayed union (1) or nonunion (12).
of A0 implants used
Implants Associated injuries Head injury Thoracic injury Abdominal injury Pelvic fracture Upper limb Lower limb (thigh and ankle)
No.
No. 14 3 1 3 4 13
fixation done as a primary treatment. The reasons for delaying operation in the remaining 63 fractures are summarized in Table ZZZ. The most frequent reason was given as ‘ Others ‘, meaning that the condition of the skin was definitely poor or doubtful. Most patients who were not primarily operated upon, were treated by skeletal traction using a calcaneal pin. Of the 13 fractures subjected to secondary internal fixation, only 2 had been operated on before the A0 operation (with a vitallium plate and a Lane’s plate, respectively). The types of A0 implants used are summarized in Table IV. Eight-hole plates were most commonly used. In 16 fractures, the plate was applied medially, in 68 laterally, and in 1 posteriorly. Axial compression of the fracture was obtained by the use of the A0 tension device in 17 cases and interfragmentary compression with lag screws in 47 cases. In the remaining patients the plates were placed under tension by bending
Lag screws only Tibia1 plates 6-hole plate g-hole plate and lag screws 7-hole plate 7-hole plate and lag screws 8-hole plate 8-hole plate and lag screws 8-hole plate dually g-hole plate g-hole plate and lag screws 1 O-plate 1 O-hole plate and lag screws 12-hole plate 15-hole plate Femoral plates Buttress plate and lag screws Condylar plates Total
15 3 5 9 6 17 14 1 8 8 3 2 2 1 2 1 3 100
use of the thick and broad femoral plate in two cases must be, at best, considered unnecessary. Cancellous bone autografts were used in 8 fractures and bone cement in the screw-holes in one case with severe osteoporosis. Grafting was used for biomechanical reasons to fill bone defects in comminuted fractures, as recommended by Mullet-, Allgower, and Willenegger (1970) and in a few cases of atrophic non-union.
216
Injury:
the British Journal
of Accident
Surgery
Vol. ~/NO. 3
Fig. 4.-A, Female, aged 68. Traffic accident. Closed cornminuted fracture. Traction for 8 days. B, Rigid internal fixation with two cortical lag screws and a tension-band plate. Plaster for 3 months. C, One year later, sound union and normal function.
Fig. 5.-A,
Male, aged 71. Traffic accident. Torsion fracture. B, Immediate operation. Rigid internal fixation with two lag screws and a tension-band plate. No plaster. C, Sound union and normal function 6 months later.
Solheim
: Tibia1
A
Fractures
217
B
C
Male, aged 44. Trathc accident. Cornminuted segmental fracture. Traction for 9 days. B, Open reduction and rigid internal fixation with one cortical lag screw and a tension-band plate medially. Plaster immobilization for 3 months. Full weight-bearing at 4 months. Fig. 6.-A,
B, Female, aged 36, car driver, injured in collision, sustaining a head injury, fracture of the mandible, pelvis and left lower leg. A few hours after admission, after ensuring that her vital signs were stable, her mandibular fracture and leg fractures were openly reduced and rigid tixation of her tibia1 fracture was obtained, using two lag screws and a lo-hole tension-band plate medially. The fracture was much more cornminuted than was apparent from the X-ray films. C, The postoperative course was uneventful and 14 months later the plate and the screws were removed without complication. The function of the limb was normal.
Fig. 7.-A,
Injury
218
Postoperative plaster was used in 36 patients, for l-6 months (mean 2.8 months). The patients usually had the plaster applied before discharge from hospital, but while in hospital they were encouraged to exercise the injured limb actively. They were fully weight-bearing in most cases after 34 months, but in a few cases up to 6 months.
: the
British Journal of Accident
Surgery Vol. ~/NO. 3
the patient was subsequently lost to follow-up. In the fourth, infection persisted for 3 months but then subsided and the fracture went on to normal union and function. Non-union occurred in one patient who was a 49-year-old man with a severe head injury and bilateral comminuted fractures after a traffic accident. A0 internal fixation of both fractures
Fig. 8.-A, Male, aged 51, was knocked down by a car. An open, segmental tibia1 fracture was treated by skeletal traction and closure of the small puncture wound. B, Eleven months later, after continuous plaster treatment, non-union of the middle fracture was obvious. C, Four months after operation using an ll-hole tensionband plate. Rigid fixation was obtained and no plaster was used. At follow-up 23 years later, function was normal.
RESULTS
(Table V)
was performed 2 weeks after the injury and normal union took place on one side while nonunion occurred on the other. The failure of union was probably due to incorrect application of the plate (compression was not obtained and in fact distraction seemed to persist after the rigid internal fixation). The implants were removed and intramedullary nailing performed
Four cases of deep infection were encountered. In one, the fracture went on to normal union and normal function, and the sinus healed after removal of the implants. In one, osteomyelitis developed and a discharge still persists after removal of the implants, although the fracture has healed and the function is almost normal. In one, deep infection persisted for 4: months but
Tab/e
\/.-Patients
Time between and operation
9).
with tibia1 fractures injury
Within 8 hours Within 2 weeks 15 days-4 weeks 3-l 2 months
Totals
(Fig.
fnfection 2 2 -
Mafunion -
1
1
-
Normal at fo,fow_up
Tota,
3 3
35 38 8 12
37 40
6
93
98
Re-fracture
-
1
4
Non-union
-
1
Solheim
: Tibia1
Fractures
219
Malunion was found in one patient, whose fracture healed with 15” of forward bowing and 5” of valgus, but with normal function.
A
B
In a series of 500 cases in the 1 S-year period up to 1954, the results were satisfactory (Solheim, 1960). However, the A0 implants, tools, and
C
D
Fig. 9.-A, Male, aged 49. Traffic accident. Severe head injury and bilateral comminuted leg fractures. Traction for 2 weeks. B, Open reduction and internal fixation of both leg fractures 2 weeks after the accident. On the right side grafting with autogenous cancellous bone into medial bone defect. One cortical lag screw and a tension-band plate. Note failure of compression and angulation. C, One year later, removal of implants due to obvious non-union. D. The non-union was treated with closed intramedullary nailing after reaming of the medullary canal resulting’in normal union.
Re-fracture occurred in 6 fractures but all went on to normal union after immobilization in plaster. Three patients fell, 2 of whom were under the influence of alcohol, 3 weeks, 5 and 14 months after operation. In 2 of them, lag screw fixation only had been used, while in the third, plating had been performed. In three plated fractures the implants were removed 1 year after the operation, and shortly afterwards, re-fracture occurred from minor trauma. Otherwise, the results were excellent, with healing in normal alinement and with normal or almost normal function of the limb. At the time of the follow-up, the implants had been removed in 27 patients.
DISCUSSION Our first 4 years of experience with the A0 treatment of tibia1 fractures has been encouraging. Operative treatment of fractures has been frequently used in our department for a long time according to the principles of open reduction, internal fixation, and early mobilization.
technique represent a definite advance in operative fracture treatment, provided that they are used according to sound biomechanical principles and by surgeons well trained in the operative treatment of fractures. As in all methods, however, failures will be encountered. In most cases, absolutely rigid internal fixation can be achieved, allowing early exercise of muscles and joints to counteract the ‘ fracture disease ’ of Danis (1949). The rigid fixation obtained at operation may, however, give a false sense of security and it will not always withstand a sudden twist or heavy fall of the patient. If external splintage is dispensed with, the patient’s activities must be carefully limited if the implant (or the bone itself) is not to fail, as was emphasized by Freeman and Swanson (1970). This has also been our experience, especially in oblique fractures internally fixed with lag screws only and not supplemented by plaster. If the length of the fracture line is less than twice the diameter of the bone at that level, it is mandatory to use a supplementary neutralization plate (Mtiller,
220
Injury:
AllgGwer, and Willenegger, 1970) if it is not proposed to use additional external immobilization with plaster. Rigid internal fixation will result in union almost without radiographically visible callus and this may make it difficult to decide when the fracture has healed. As in all operative treatment of fractures, including the A0 method, infection is the greatest hazard. The 4 per cent incidence of deep infection in our series is rather high. However, in 2 patients the infection subsided and normal function was obtained. One patient was lost to follow-up and one developed chronic osteomyelitis. One may speculate whether the necessarily wider exposure and longer operation may predispose to infection. This may be avoided by a wider use of medullary nailing, which the A0 group also recommends. Enviable results with this technique have been reported (Zucman and Maurer, 1970). As was stressed by London (1967), even a cursory glance at the literature on tibia1 fractures makes it painfully clear that a great deal of harm has been done by ill-judged, ill-performed, and unnecessary surgery. Though well aware of the recommendations of Watson-Jones (1956), Ellis (1958), Dehne, Metz, Deffer, and Hall (1961), Nicoll (1964), London (1967), Anderson (1971), and others on closed treatment, we still believe that rigid internal fixation has a definite place in the treatment of tibia1 fractures, and that the excellent instrumentation and the sound biomechanical technique and principles of the A0 are most valuable in this respect. Our experience from the first 4 years’ use of the A0 method supports this, as do the results of Batten (1969), although we agree with Wade (1970) that A0 has a problem. The majority of tibia1 fractures in the present series fell into the category that London (1967) describes as difficult. Only one case of nonunion was encountered and this was due to technical failure early in the period. Requests
for reprints should
be addressed
to:-Dr.
K. Solheim,
the British Journal
of Accident
Surgery
Vol. ~/NO. 3
The A0 group recommend that the implants should be removed from the lower limb after union of the fracture. We have seen some cases of re-fracture after premature removal (one year) and strongly recommend that the implants are not removed until 13-2 years after the operation, and that the patient is advised to be careful following the removal of the metal. REFERENCES ANDERSON, L.
Orthopaedics
D.
(ed.
(1971), in Campbell’s CRENSHAW, A. H.).
Operative
St. Louis:
Mosby. BATTEN, R.
L. (1969), ‘The place of compression technique in the management of long bone fractures in an industrial city ‘, J. Bone Jt Surg., 51B,
177. DANIS,
R.
(1949),
Theorie
et Pratique
de I’Osteo-
Paris: Masson.
synthise.
DEHNE, R., METZ, C. W., DEFFER, P. A., and HALL, R. M. (1961), ‘ Non-operative treatment of the
fractured tibia by immediate weight bearing ‘, J. Trauma, 1, 514. ELLIS, H. (1958), ‘ The speed of healing after fracture of the tibia1 shaft ‘, J. Bone Jt Surg., 40B, 42. FREEMAN, M. A. R., and SWANSON, S. A. V. (1970), ’ Implants in the treatment of fractures: Engineering considerations ‘, in Modern Trends in Accident Surgery and Medicine 2 (ed. LONDON, P. S.). London: Butterworths. LONDON, P. S. (1967), A Practical
the Injured.
Guide to the Care of
Edinburgh
and London: Livingston& ALLG~~WER, M., and WILLENEGGER,
MUELLER,M. E., H. (1965), Technique
of Internal
Fixation
of Frac-
Berlin: Springer. - - - - - - (1970), Manual qf internal Fixation, Berlin: Springer. NICOLL, E. A. (1964), ‘ Fractures of the tibia1 shaft. A survey of 705 cases ‘. J. Bone Jt Surg., 46B, 373. SOLHEIM, K. (1960), ‘ Fractures of the lower leg ‘, tures.
Acta chir. stand., WADE,
P.
A.
119, 268.
(1970),
‘ ASIF
compression
has a
problem ‘, J. Trauma, 10, 513. WATSON-JONES,R. (1956), Fractures
and Joint Injuries.
Edinburgh and London: Livingstone. ZUCMAN, J., and MAURER, P. (1970), ‘ Primary medullary nailing of the tibia for fractures of the shaft in adults ‘, Injury, 2, 84.
SurgicalDepartmentIII, Ullevil Hospital,Norway.
213
Tibia1 fractures treated the AO* method
according
to
K. Solheim Surgical Department Ill, UlJevBl Hospital, Norway
A series of the first 100 tibia1 fractures treated in a general surgical department according to the A0 method is presented. One case of non-union, due to technical failure was encountered. Four cases of deep infection occurred. Two of these subsided after removal of the metal. Re-fracture was a problem occurring for different reasons in 6 patients. Most of the fractures were difficult ones and it is concluded that the A0 method is a definite advance in the operative treatment of tibia1 fractures. THE treatment of adult tibia1 shaft fractures is a much disputed topic. It is not the purpose of this paper to go into detail in this discussion but to review the results of operative treatment according to the A0 method in a general surgical department. This method, based on the experimental and clinical work of many workers and
introduced 10 years ago, seems in expert hands to yield admirable results (Mi.iller, Allgower, and Willenegger, 1965) and it is understandable that the A0 implants, technique, and principles have achieved widespread use. We have used them since 1967.
THE
SERIES
From 1967 to 1970 inclusive, 98 patients with 100 tibia1 shaft fractures have been treated by the A0 technique. Two patients had bilateral fractures. The case histories have been reviewed and the patients followed up clinically and radiologically from 6 months to e years. Only 10 patients were observed for less than a year. Age and sex distribution are shown in Fig. 1. The causes of injury are shown in Table I. More than half of the patients were injured in
Females
Males IIIII
10-19
20-29
30-39
40-49
50-59
60-69
70-79
80-89 Age
Fig. I.-Tibia1
shaft fractures.
*Arbeitsgemeinschaft
Distribution
fiir Osteosynthesefragen.
by age and sex.
groups
214
Injury:
A
the British
Journal
of Accident
Surgery
Vol. ~/NO. 3
C
B
Male, aged 18. Skiing accident. Spiral fracture in lower third. Traction for 9 days. Closed reduction unsuccessful. B, Open reduction and internal fixation with three lag screws. Plaster for 10 weeks. Full weight-bearing at 14 weeks. C, Seven months after the accident. Sound union and normal function.
Fig. 2.-A,
A
B
C
Fig. 3.-A, Female, aged 50. Traffic accident. Cerebral concussion, rib fractures, subtrochanteric femoral fracture, ankle fracture, and comminuted tibia1 fracture with butterfly fragment. Traction for 12 days. B, At one operation, rigid internal fixation of all fractures, using an angled blade-plate nail for the femoral fracture, two lag screws and a tension-band plate for the tibia1 fracture, and malleolar screws for the ankle fracture. The tibia1 fracture would have been treated conservatively if this had been the only injury. No plaster was used. C, Sound union and normal function one year later.
Solheim : Tibia1 Fractures
215
traffic accidents, in which comminuted fractures were common (in 46 patients) and often caused by direct violence (in 43 patients). The fractures were open in 19 cases and 3 patients had segmental fractures. Eighteen patients had severe associated injuries (Table II).
Table///.-Circumstances undertaken
TREATMENT Close attention was paid to the soft tissues, especially to the skin overlying the fracture. This is why in only 37 fractures was internal Tab/e /.-Causes
of the injury
Cause
No. of patients
Traffic accidents Accidents at work Accidents at sport and games Falls on the same level indoors Falls on the same level outdoors
55 5 14 5 19
Tota I
98
Tab/e //.-Severe in 18 patients
them and fixing them to the bone in the special way recommended by the A0 group, or used as neutralization plates. Figs. 2-8 illustrate some of the applications. The longest plates were used in the segmental and comminuted fractures. Our
associated injuries
in which A0 treatmentwas
Treatment
No. of fractures
Primary internal fixation Delayed primary fixation
37 50
Secondary internal fixation
Tab/e /K--Types
13
Notes
Unsuccessful reduction, 7. Priority for treatment of associated injuries, poor skin, etc., 43. Within 2 weeks, 42; within 2-4 weeks, 8. At 3-12 months. Because of delayed union (1) or nonunion (12).
of A0 implants used
Implants Associated injuries Head injury Thoracic injury Abdominal injury Pelvic fracture Upper limb Lower limb (thigh and ankle)
No.
No. 14 3 1 3 4 13
fixation done as a primary treatment. The reasons for delaying operation in the remaining 63 fractures are summarized in Table ZZZ. The most frequent reason was given as ‘ Others ‘, meaning that the condition of the skin was definitely poor or doubtful. Most patients who were not primarily operated upon, were treated by skeletal traction using a calcaneal pin. Of the 13 fractures subjected to secondary internal fixation, only 2 had been operated on before the A0 operation (with a vitallium plate and a Lane’s plate, respectively). The types of A0 implants used are summarized in Table IV. Eight-hole plates were most commonly used. In 16 fractures, the plate was applied medially, in 68 laterally, and in 1 posteriorly. Axial compression of the fracture was obtained by the use of the A0 tension device in 17 cases and interfragmentary compression with lag screws in 47 cases. In the remaining patients the plates were placed under tension by bending
Lag screws only Tibia1 plates 6-hole plate g-hole plate and lag screws 7-hole plate 7-hole plate and lag screws 8-hole plate 8-hole plate and lag screws 8-hole plate dually g-hole plate g-hole plate and lag screws 1 O-plate 1 O-hole plate and lag screws 12-hole plate 15-hole plate Femoral plates Buttress plate and lag screws Condylar plates Total
15 3 5 9 6 17 14 1 8 8 3 2 2 1 2 1 3 100
use of the thick and broad femoral plate in two cases must be, at best, considered unnecessary. Cancellous bone autografts were used in 8 fractures and bone cement in the screw-holes in one case with severe osteoporosis. Grafting was used for biomechanical reasons to fill bone defects in comminuted fractures, as recommended by Mullet-, Allgower, and Willenegger (1970) and in a few cases of atrophic non-union.
216
Injury:
the British Journal
of Accident
Surgery
Vol. ~/NO. 3
Fig. 4.-A, Female, aged 68. Traffic accident. Closed cornminuted fracture. Traction for 8 days. B, Rigid internal fixation with two cortical lag screws and a tension-band plate. Plaster for 3 months. C, One year later, sound union and normal function.
Fig. 5.-A,
Male, aged 71. Traffic accident. Torsion fracture. B, Immediate operation. Rigid internal fixation with two lag screws and a tension-band plate. No plaster. C, Sound union and normal function 6 months later.
Solheim
: Tibia1
A
Fractures
217
B
C
Male, aged 44. Trathc accident. Cornminuted segmental fracture. Traction for 9 days. B, Open reduction and rigid internal fixation with one cortical lag screw and a tension-band plate medially. Plaster immobilization for 3 months. Full weight-bearing at 4 months. Fig. 6.-A,
B, Female, aged 36, car driver, injured in collision, sustaining a head injury, fracture of the mandible, pelvis and left lower leg. A few hours after admission, after ensuring that her vital signs were stable, her mandibular fracture and leg fractures were openly reduced and rigid tixation of her tibia1 fracture was obtained, using two lag screws and a lo-hole tension-band plate medially. The fracture was much more cornminuted than was apparent from the X-ray films. C, The postoperative course was uneventful and 14 months later the plate and the screws were removed without complication. The function of the limb was normal.
Fig. 7.-A,
Injury
218
Postoperative plaster was used in 36 patients, for l-6 months (mean 2.8 months). The patients usually had the plaster applied before discharge from hospital, but while in hospital they were encouraged to exercise the injured limb actively. They were fully weight-bearing in most cases after 34 months, but in a few cases up to 6 months.
: the
British Journal of Accident
Surgery Vol. ~/NO. 3
the patient was subsequently lost to follow-up. In the fourth, infection persisted for 3 months but then subsided and the fracture went on to normal union and function. Non-union occurred in one patient who was a 49-year-old man with a severe head injury and bilateral comminuted fractures after a traffic accident. A0 internal fixation of both fractures
Fig. 8.-A, Male, aged 51, was knocked down by a car. An open, segmental tibia1 fracture was treated by skeletal traction and closure of the small puncture wound. B, Eleven months later, after continuous plaster treatment, non-union of the middle fracture was obvious. C, Four months after operation using an ll-hole tensionband plate. Rigid fixation was obtained and no plaster was used. At follow-up 23 years later, function was normal.
RESULTS
(Table V)
was performed 2 weeks after the injury and normal union took place on one side while nonunion occurred on the other. The failure of union was probably due to incorrect application of the plate (compression was not obtained and in fact distraction seemed to persist after the rigid internal fixation). The implants were removed and intramedullary nailing performed
Four cases of deep infection were encountered. In one, the fracture went on to normal union and normal function, and the sinus healed after removal of the implants. In one, osteomyelitis developed and a discharge still persists after removal of the implants, although the fracture has healed and the function is almost normal. In one, deep infection persisted for 4: months but
Tab/e
\/.-Patients
Time between and operation
9).
with tibia1 fractures injury
Within 8 hours Within 2 weeks 15 days-4 weeks 3-l 2 months
Totals
(Fig.
fnfection 2 2 -
Mafunion -
1
1
-
Normal at fo,fow_up
Tota,
3 3
35 38 8 12
37 40
6
93
98
Re-fracture
-
1
4
Non-union
-
1
Solheim
: Tibia1
Fractures
219
Malunion was found in one patient, whose fracture healed with 15” of forward bowing and 5” of valgus, but with normal function.
A
B
In a series of 500 cases in the 1 S-year period up to 1954, the results were satisfactory (Solheim, 1960). However, the A0 implants, tools, and
C
D
Fig. 9.-A, Male, aged 49. Traffic accident. Severe head injury and bilateral comminuted leg fractures. Traction for 2 weeks. B, Open reduction and internal fixation of both leg fractures 2 weeks after the accident. On the right side grafting with autogenous cancellous bone into medial bone defect. One cortical lag screw and a tension-band plate. Note failure of compression and angulation. C, One year later, removal of implants due to obvious non-union. D. The non-union was treated with closed intramedullary nailing after reaming of the medullary canal resulting’in normal union.
Re-fracture occurred in 6 fractures but all went on to normal union after immobilization in plaster. Three patients fell, 2 of whom were under the influence of alcohol, 3 weeks, 5 and 14 months after operation. In 2 of them, lag screw fixation only had been used, while in the third, plating had been performed. In three plated fractures the implants were removed 1 year after the operation, and shortly afterwards, re-fracture occurred from minor trauma. Otherwise, the results were excellent, with healing in normal alinement and with normal or almost normal function of the limb. At the time of the follow-up, the implants had been removed in 27 patients.
DISCUSSION Our first 4 years of experience with the A0 treatment of tibia1 fractures has been encouraging. Operative treatment of fractures has been frequently used in our department for a long time according to the principles of open reduction, internal fixation, and early mobilization.
technique represent a definite advance in operative fracture treatment, provided that they are used according to sound biomechanical principles and by surgeons well trained in the operative treatment of fractures. As in all methods, however, failures will be encountered. In most cases, absolutely rigid internal fixation can be achieved, allowing early exercise of muscles and joints to counteract the ‘ fracture disease ’ of Danis (1949). The rigid fixation obtained at operation may, however, give a false sense of security and it will not always withstand a sudden twist or heavy fall of the patient. If external splintage is dispensed with, the patient’s activities must be carefully limited if the implant (or the bone itself) is not to fail, as was emphasized by Freeman and Swanson (1970). This has also been our experience, especially in oblique fractures internally fixed with lag screws only and not supplemented by plaster. If the length of the fracture line is less than twice the diameter of the bone at that level, it is mandatory to use a supplementary neutralization plate (Mtiller,
220
Injury:
AllgGwer, and Willenegger, 1970) if it is not proposed to use additional external immobilization with plaster. Rigid internal fixation will result in union almost without radiographically visible callus and this may make it difficult to decide when the fracture has healed. As in all operative treatment of fractures, including the A0 method, infection is the greatest hazard. The 4 per cent incidence of deep infection in our series is rather high. However, in 2 patients the infection subsided and normal function was obtained. One patient was lost to follow-up and one developed chronic osteomyelitis. One may speculate whether the necessarily wider exposure and longer operation may predispose to infection. This may be avoided by a wider use of medullary nailing, which the A0 group also recommends. Enviable results with this technique have been reported (Zucman and Maurer, 1970). As was stressed by London (1967), even a cursory glance at the literature on tibia1 fractures makes it painfully clear that a great deal of harm has been done by ill-judged, ill-performed, and unnecessary surgery. Though well aware of the recommendations of Watson-Jones (1956), Ellis (1958), Dehne, Metz, Deffer, and Hall (1961), Nicoll (1964), London (1967), Anderson (1971), and others on closed treatment, we still believe that rigid internal fixation has a definite place in the treatment of tibia1 fractures, and that the excellent instrumentation and the sound biomechanical technique and principles of the A0 are most valuable in this respect. Our experience from the first 4 years’ use of the A0 method supports this, as do the results of Batten (1969), although we agree with Wade (1970) that A0 has a problem. The majority of tibia1 fractures in the present series fell into the category that London (1967) describes as difficult. Only one case of nonunion was encountered and this was due to technical failure early in the period. Requests
for reprints should
be addressed
to:-Dr.
K. Solheim,
the British Journal
of Accident
Surgery
Vol. ~/NO. 3
The A0 group recommend that the implants should be removed from the lower limb after union of the fracture. We have seen some cases of re-fracture after premature removal (one year) and strongly recommend that the implants are not removed until 13-2 years after the operation, and that the patient is advised to be careful following the removal of the metal. REFERENCES ANDERSON, L.
Orthopaedics
D.
(ed.
(1971), in Campbell’s CRENSHAW, A. H.).
Operative
St. Louis:
Mosby. BATTEN, R.
L. (1969), ‘The place of compression technique in the management of long bone fractures in an industrial city ‘, J. Bone Jt Surg., 51B,
177. DANIS,
R.
(1949),
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