Treatment of open fractures of the shaft of the tibia

Abstract

We have systematically reviewed the effect of alternative methods of stabilisation of open tibial fractures on the rates of reoperation, and the secondary outcomes of nonunion, deep and superficial infection, failure of the implant and malunion by the analysis of 799 citations on the subject, identified from computerised databases. Although 68 proved to be potentially eligible, only eight met all criteria for inclusion. Three investigators independently graded the quality of each study and extracted the relevant data. One study (n = 56 patients) suggested that the use of external fixators significantly decreased the requirement for reoperation when compared with fixation with plates. The use of unreamed nails, compared with external fixators (five studies, n = 396 patients), reduced the risk of reoperation, malunion and superficial infection. Comparison of reamed with unreamed nails showed a reduced risk of reoperation (two studies, n = 132) with the reamed technique. An indirect comparison between reamed nails and external fixators also showed a reduced risk of reoperation (two studies) when using nails. We have identified compelling evidence that unreamed nails reduced the incidence of reoperations, superficial infections and malunions, when compared with external fixators. The relative merits of reamed versus unreamed nails in the treatment of open tibial fractures remain uncertain.

Which Surgical Treatment for Open Tibial Shaft Fractures Results in the Fewest Reoperations? A Network Meta-analysis

“…The three categories for agreement were agreement, disagreement, and partial agreement (in instances where it was unclear to us whether the trial should be included). We chose an a priori criterion of a kappa of 0.65 or greater as adequate agreement [3,33].…”

“…There have been numerous systematic reviews using traditional head-to-head meta-analyses for tibial shaft fracture management [3,4,7,11,26,31,47]. Of these, only one evaluated [3] an intervention other than reamed or unreamed nailing. In addition, among the reviews comparing reamed and unreamed intramedullary nailing, open fracture data generally have been underemphasized, methods have been poor (eg, exclusion of nonEnglish studies), and CIs have been very wide.…”

“…Previous reviews have focused on intramedullary nailing and have been based on a small number of trials [3,4]. There has been a resurgence of randomized trials evaluating different treatment modalities for open fractures, including comparisons of reamed with unreamed intramedullary nailing [27,40,42]; intramedullary nailing with ender nailing [41]; intramedullary nailing with external fixation [30,39]; external fixation (AO) with the Ilizarov technique [12]; and plate osteosynthesis with intramedullary nailing [45].…”

Infection resistance of unreamed solid, hollow slotted and cannulated intramedullary nails: An in‐vivo experimental comparison

“…Several in-vivo investigations on the effects of orthopedic implants on the incidence of local infection have been reported [24,20-221. Because conventional intramedullary nailing with hollow slotted nails and reaming of the medullary cavity is believed to impair the endosteal blood supply [26] and impair infection resistance [ 16,271, an alternative was found in the application of small diameter solid nails inserted without reaming. The solid nail has gained greatly in acceptance and is even used with reaming today, but the treatment of open tibia fractures remains controversial [6,7,[17][18][19]. To overcome some difficulties of insertion with the solid nail, especially in cases of comminution and or displaced fractures, the cannulated nail was developed to be used with a guide wire.…”

Osteossíntese provisória das fraturas expostas da diáfise da tíbia com fixador externo não transfixante

“…Devido ao mecanismo de trauma e à escassa cobertura cutânea ântero-medial, a tíbia é o osso longo que mais freqüentemente sofre fratura exposta (1)(2)(3)(4)(5)(6) . Entre as causas mais freqüentes estão os traumas de alta energia, os acidentes automobilísticos, motociclísticos e atropelamentos, além das fraturas em conseqüência de ferimento por projétil de arma de fogo.…”