A prospective study on clinical outcome of primary nailing in open Type I to Type IIIA tibial diaphyseal fractures

Kiran Hari; KM Srinath; Ravi M Daddimani

doi:10.4103/jodp.jodp_37_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 5 | Issue : 2 | Page : 56-60

A prospective study on clinical outcome of primary nailing in open Type I to Type IIIA tibial diaphyseal fractures

Kiran Hari, KM Srinath, Ravi M Daddimani
Department of Orthopaedics, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India

Date of Submission	07-Dec-2021
Date of Decision	25-Jan-2022
Date of Acceptance	26-Jan-2022
Date of Web Publication	28-May-2022

Correspondence Address:
Ravi M Daddimani
Dept of Orthopaedics, SDM College of Medical Sciences and Hospital, Dharwad - 580 009, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_37_21

Abstract

Background and Objectives: Tibia is a superficial long bone, with one third of its surface being subcutaneous. An increasing incidence of road traffic accidents, farm accidents, gunshot wound predisposes it for open fracture. Open fractures of the tibia are the most common open long bone fractures. High-energy trauma is the primary mechanism of injury, with over 50% of cases being attributed to road traffic accidents are frequently contaminated. The treatment of open tibia fractures is still controversial. This prospective study was conducted at a tertiary care trauma center to evaluate the functional outcome and complications following primary debridement and nailing in type I to type IIIA open tibia fractures. Materials and Methods: A total of 30 patients diagnosed with open tibial diaphyseal fractures, who underwent primary debridement and fixation with intramedullary interlocking nail were included in the study and type III B, type III C open fractures were excluded. Patients were followed for a period of 12 months and assessed using Modified Ketenjian criteria and Johner − Wruhs' criteria. Results: Out of 30 patients who underwent primary nailing for open tibia fractures, 66.67% had excellent, 26, 67% good, and 6.66% of patients had fair results. 93.33% of the patients had union within 9 months and 6.66% of the cases had delayed union. Conclusion: Primary intramedullary interlocking nailing in open tibia fractures is a good treatment option, it aids early patient mobilization and early resume to work. It avoids multiple surgical procedures and promotes early fracture union.

Keywords: Debridement, open tibia fractures, primary nailing

How to cite this article:
Hari K, Srinath K M, Daddimani RM. A prospective study on clinical outcome of primary nailing in open Type I to Type IIIA tibial diaphyseal fractures. J Orthop Dis Traumatol 2022;5:56-60

How to cite this URL:
Hari K, Srinath K M, Daddimani RM. A prospective study on clinical outcome of primary nailing in open Type I to Type IIIA tibial diaphyseal fractures. J Orthop Dis Traumatol [serial online] 2022 [cited 2023 Jun 6];5:56-60. Available from: https://jodt.org/text.asp?2022/5/2/56/346213

Introduction

Tibia is a superficial long bone, with one-third of its surface being subcutaneous. An increasing incidence of road traffic accidents, farm accidents, gunshot wound predisposes it for open fracture. Open fractures of the tibia are the most common open long bone fractures, with an annual incidence of 3.4/100,000. High-energy trauma is the primary mechanism of injury, with over 50% of cases being attributed to road traffic accidents or fall from height and are frequently contaminated. Majority of fractures occur <40 years of age. Therefore, open tibial fractures lead to significant morbidity, deformity, disability, poor cosmetics, causing loss of working days and economic burden in working age group. Treatment of open tibia fractures is still controversial and challenging. There are various treatment methods used in the management of open tibia fractures which include debridement, open reduction, and fixation modality depends on intraoperative assessment of wound contamination, soft-tissue coverage, and amount of bone loss. External fixation is extremely popular in recent years. However, pin-tract infections, malunion, nonunion, and bulky frames limited the use of external fixators. External fixation also increases the time of hospital stay, financial burden as there is high incidence of re-surgeries. Hence, external fixators are used only as temporary treatment modality till soft-tissue healing is attained.

The increasing use of immediate antibiotics, aggressive and repeated debridement, fracture stabilization by intramedullary nailing, and early soft-tissue coverage, has greatly reduced the rates of infection and nonunion and helps in attaining better functional outcome. Hence, primary debridement and interlocking nailing are a valid option in the treatment of open tibia fracture. In this study, we aim to assess the clinical and radiological outcome of open tibia fractures treated with primary debridement and interlocking nailing.

Materials and Methods

The present study is a hospital-based prospective study conducted at SDM College of Medical Sciences and Hospital Dharwad, after obtaining Ethical Clearance from our Institutional Ethical Committee. All patients more than 18 years presenting to the emergency department with open tibial type I, type II, and type IIIA fractures were included in the study. After hemodynamic stabilization of the patient in the emergency room, radiographs were obtained and clinically assessed according to Gustilo − Anderson grading. Fractures with intra-articular extension, pediatric age group, type IIIB, C and ipsilateral femur fracture were excluded from the study. Patients were treated with analgesics and antibiotics (a cephalosporin, an aminoglycoside, and a nitroimidazole) tetanus vaccine and immunoglobulin. Thorough wound wash with normal saline, chlorhexidine, cetremide solution, and hydrogen peroxide given in the emergency room. The patients were then taken up for surgery at the earliest. Antibiotics were repeated intraoperatively if the surgery goes beyond 4 hours of 1^st dose. Thorough wound debridement carried out in the operation room. The open wound over the leg was extended, fracture site and medullary canal was cleared of any debris. All the contaminants were debrided. [Figure 1] after taking entry point beaded guide wire was passes and serial reaming was done with flexible reamers. After inserting appropriate size nail proximal locking done through the zig in static mode and distal locking done with the free hand technique. In all patients', titanium nail was used. (Abone Company Manufactured). Then, wound wash given using 4–5 l of normal saline. Wound closure was done over suction drain. Cases where wound closure were not possible which required split skin graft or flaps by plastic surgeons were excluded from the study as they come under type IIIB. Postoperatively, intravenous antibiotics, cefuroxime 750 mg, amikacin 500 mg and metronidazole were given for 5 days and oral cefuroxime 500 mg twice a day was given for 2 weeks for antibiotic suppression to prevent infection. Intraoperative cultures were not sent, postoperative culture and sensitivity were sent in four cases who had infections. Inflammatory markers like C-reactive protein, total white blood cell count, and erythrocyte sedimentation rate were done when wound showed signs of infection on first dressing on postoperative day 2. In three patients' organism found was staph aureus and one patient with deep infection had methicillin-resistant staph aureus (MRSA) who was treated with nail removal, debridement and posterior slab application in the first stage with oral linezolid 600 mg twice a day and in second stage definitive ring illizarov fixation was done. As shown in [Figure 2], postoperatively, mobilization of knee and ankle started on day 1 and weight-bearing mobilization was done based on fracture pattern, majority of patients were mobilized partial weight bearing with walker at the end of 4 weeks. Postsurgery, patients were followed up at 4 weeks, 3 months, 6 months, and 1 year with clinical examination for any complications and radiographs were done. As shown in [Figure 3], postoperatively, oral antibiotics were given for 2 weeks. Recovery pattern in type I group, out of 15 patients, 12 had excellent results, 3 had good results, and none had fair results. In type II group of patients, out of 5, 3 had excellent and 2 had good results. In type III group, out of 10 patients, 5 had excellent results, 3 had good results, and 2 had fair results. One had deep infection with MRSA who underwent two staged procedures with implant removal debridement and ring illizarov fixation.

Figure 1: Picture showing preoperative and postoperative clinical wounds

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Figure 2: Picture showing postoperative complication, deep infection with sinus formation

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Figure 3: Radiographs showing preoperative and 1-year follow-up radiographs

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Results

The study included 30 patients with a mean age of 39.2 years, 43.3% patients in the age group of 18–30 years. There were 24 males and 6 females in the study, 80% of patients were males. Road traffic accident was the most common mode of injury accounting for 83.3%. Right side was involved in 18 patients accounting for 60%. Majority of patients' fracture was involved in the middle third shaft of tibia. Out of 30 patients, 15 were of type I, 5 types II, and 10 type IIIA open fractures [Table 1]. Mobilization of the patients was determined by fracture pattern. Patients were mobilized partial weight bearing according to the fracture pattern. Majority of the patients mobilized partial weight bearing with walker after 4 weeks. Commencement of full weight bearing done at the end of 12 weeks according to serial follow up radiographs depending on progression of fracture union and patient comfort. Average time of union of the fracture in the present study was 28 weeks. Out of 30 patients, 3 had superficial surgical site infection which was treated with debridement and IV antibiotics. One patient had deep infection which was treated with implant removal, debridement and illizarov ring fixator in the two stage procedure. Patients with superficial infection belonged to type II open fractures. One patient with deep infection belonged to type IIIA open fracture. Majority of the patients in the study had excellent clinical outcome without any complications. 66.67% of the patients had excellent outcome. 26.67% of the patients had good outcome and 6.67% patients had fair outcome based on Johnerand Wruh's criteria, modified Ketenjian's criteria [Table 2]. Average time of fracture union in the present study was 28 weeks. Maximum time taken for fracture union was 60 weeks and minimum time for union was 17 weeks. Average union time for type 1, type II, and type IIIA was 6.25, 6.27, and 8.25 in months, respectively. The statistical method used to analyze the results was univariate ANOVA test.

Table 1: Demographic details

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Table 2: Functional outcome based on Modified Ketenjian's criteria

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Discussion

In the present study, there were 24 male patients and 6 female patients were included in the study. A study by Court-Brown et al. revealed that 69.1% of the fractures occurred in males and 30.9% were occurred in females' years.^[1] They noted that it is younger males who are prone to sustain open fractures as a result of sport, falls from a height, road traffic accidents and direct blows or assaults. Morgan Laigle et al. in their study showed that 72% of open tibia fractures occurred in male an 18% of the fractures occurred in females.^[2] In our study, male patients were of working age group and need to travel more than the female population. This may explain the male preponderance in the incidence of open tibia fractures. In the present study, majority of the patients who sustained open tibia fracture belong to the age group between 18 and 40 years. A total of 19 patients belong to this age group. It constitutes about 63.33% patients. Eleven patients were of above 40 years of age, it constituted for 36.67% of the patients. The average age of the patient in the current study was 39.6 years. This suggests the highest number tibia fractures in young individuals. Average age of the patient was 40.3 in the study by Morgan Laigle et al. Christian David Weber et al. observed that average age of open tibia fracture was 46.2 in their study named “Epidemiology of open tibia fractures in a population-based database: update on current risk factors and clinical implications.”^[3] The aim of the primary nailing in open tibia fracture is to achieve bony union and early mobilization of the patient for their daily routine. Fracture union was considered when patient is able to full weight bearing without pain; fracture site is not tender on palpation and radiograph showed bridging callus. D Joshi et al., in their study on interlocking nailing in open fractures of tibia observed average time of union was 32 weeks.^[4] Average time of fracture union in the present study was 28 weeks. Maximum time taken for fracture union was 60 weeks and minimum time for union was 17 weeks. Average time fracture union in type I open fractures was 27 weeks, 27 weeks in type II fractures, 35 weeks in type III fractures, and 36 weeks in type IIIA fractures. In a study by Kellam and Singer^[5] on intramedullary nailing in open tibia observed that average time of union in Type I fractures is 19 weeks, 28 weeks in type II fractures, and 31 weeks in Type IIIA fractures. In our study, we observed that average time for union in type IIIA fracture is 36 weeks; in their study, average time for union is 31 weeks. This shows that with increased grade of injury, period of fracture union will be affected and it will lead to delayed union. Periosteum supplies blood to outer third cortex of bone. In type IIIA open injury due to periosteal injury, blood supply is hampered at the fracture site, leading to nonunion and delayed union in type IIIA fractures. In our study, 86.66% patients did not had infection and 13.33% had infection, with three superficial (10%) and one deep infection (3.33%). Superficial infection was defined as surgical site infection with redness, discharge, superficial wound tenderness and without deep bone tenderness suggested by increased acute phase reactants. Deep infection was defined as wound redness, discharge, with deep bone tenderness and suggested by increased acute-phase reactants. A study by Seron and Rasool^[6] had superficial infection rate of 10.8%, which were managed by local wound care and oral antibiotics. Deep infection rates in their study were 6.8%, which required implant removal and 82.4% of the patients had no complications.

In the present study, we noted that, majority of the open tibial shaft fractures were due to road traffic accidents. About 83.33% of cases were due to road traffic accidents. Lawrence B Bone in their study reported most of the open tibia fractures occur due to high energy trauma such as road traffic accidents.^[7] In our series of study of 30 patients, 93.33% of the fractures which underwent primary nailing for open tibia fractures resulted in union within 9 months of the injury. 6.66% of fractures had delayed union. In our series, 66.67% (20 patients) have got excellent, 26.67% (eight patients) have got good, 6.66% (two patients) have got fair outcome. In the study by Klemm and Börner^[8] reported 62.50% excellent, 31.8% good, 4.5% fair, and 1.2% had poor functional outcome. The functional outcome of majority of patients in the present study is good to excellent. It can be attributed to early antibiotic coverage and thorough wound irrigation at the time of presentation to the emergency department. These patients were taken up for operative intervention at the earliest, meticulous wound debridement, and wound closure was done.

In the present study, all the cases belonging to Type I and Type II fractures had excellent to good outcome. Twenty out of 30 patients belonged to this group. A study by Dr Raghavendra and Dr Jaipalsinh^[9] in their study of 25 patients with Type I and Type II open tibia fractures treated with intramedullary nailing reported excellent to good functional outcome in 92% of the patients. They had 1each patient with fair and poor out come in their study. In our study, majority of the patients had good to excellent outcome, this implies functional outcome in the lower grade of open fractures fracture is better contrast to higher grades of fracture. Overall, these results show that in the grade I and II open tibial fractures, a primary intramedullary interlocking nailing can be safely done, with minimal complications and excellent functional results. In a study by Dr Neelangowda et al. interlocking nailing in Type II and Type III tibia fractures had excellent to good results. In the present study we observed that 66.6% patients had excellent to good results. The present study showed that 33.33% of the patients had fair results. We observed that with higher grade of injury, overall functional outcome of the patients will be affected. The reason for fair results in these patients could be due to advanced age of the patient, severity of the injury, and soft-tissue injury at the time of injury. Furthermore, primary intramedullary nailing is superior compared to all other fixation tools, in terms of development of deep infections, provided that a good debridement of soft tissue, lavage of the fracture site and adequate antibiotic prophylaxis should be performed before nailing.^[10] The healing rates of open tibia fractures using either minimally reamed or nonreamed techniques of intramedullary nailing are comparable. No increase in the rate of infection with the reamed-to-fit technique was found.^[11] In our study, all cased were fixed with reamed inter locking nails. Manon J et al. in their study tried to evaluate the predictors of infection after primary nailing in open tibia fractures. According to this study, independent variables included age, gender, body mass index, and comorbidities, along with external factors of fracture pattern, nailing settings, and treatment processing time. A multiple logistic regression was used to identify infection risk factors. The risk of infection significantly increased according to the open grading, the fractures' classification, time until antibiotic administration, and time until nailing.^[12]

Conclusion

Primary intramedullary interlocking nailing of open tibia fracture is a safer and good treatment option, especially in type I and type II. It aids in early patient mobilization and early resume to work. It promotes early fracture union without vascular compromise at fracture site. Avoids multiple surgical procedures hence lessens the financial burden and hastens rehabilitation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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