Mechanical Failures of Intramedullary Tibial Nails Applied Without Reaming

Unreamed intramedullary nailing in distal tibial fractures

“…This compares favourably to the reports by Im and Tae [6] and Vallier et al [32] nailing groups, whereby the rate of delayed and non-union after nailing distal tibial fractures vary between 0 and 23 % in the literature [3,6,8,13,14,[22][23][24][25][26][27][28][29][30][31][32][33][34][35][36]. Screw failure remains a common problem with small diameter nails [2,15,16]. Although 55 nails were either dynamically locked or dynamised, nail migration into the ankle occurred in only one case of septic nail loosening.…”

“…Although the case for this technique has been strengthened by the introduction of locking screws to maintain fracture length, alignment and rotation, there are concerns about nail use in distal segment fractures because of several technical limitations that make fracture reduction and stable fixation difficult [2,[22][23][24]. The long-lever arm, the short segment left for distal locking and the relatively wide metaphysis that can not afford a snug endosteal fit with little nail-cortex contact prohibiting automatic fracture alignment and allowing considerable nail mobility, all can result in a higher rate of malalignment and increased stress on the locking screws with a greater risk of screw failure, nail migration or ankle penetration [2,23]. This is further complicated by intra-articular extension or ankle instability due to lateral malleolar fractures [22][23][24].…”

“…Such fractures are inherently unstable, commonly associated with soft tissue injuries and are associated with a high complication rate including malunion, non-union, wound healing problems and infection [1][2][3][4]. Wide open reduction and internal fixation (ORIF) replaced the traditional non-operative treatment of these injuries in the late 1960s.…”

“…Moreover, unreamed nailing, by preserving the endosteum, has been shown to be advantageous in polytrauma patients and in decreasing the incidence of infection in high-energy fractures [10][11][12]. Initial enthusiasm, however, was later followed by contradictory reports showing a relatively higher rate of delayed union, implant failure and reoperations after its widespread use [2,15,16]. This is further complicated in distal tibial fractures for biomechanical reasons which gave rise to a doubt about the wisdom of the general concept of favourable biological conditions such as minimal invasiveness and preservation of the intramedullary blood supply if adequate mechanical stability is missing [17,18].…”

Unreamed intramedullary locking nailing for open tibial fractures

“…The number of pseudoarthroses may indicate low stability at the fracture site. The rate of metal failure has been higher than in previous series [8,14,15,17,30,31]. This could be explained since, as we were encouraged by the initial results and by our experience with reamed nails, we encouraged early weightbearing which is not recommended with this type of osteosynthesis.…”