RESULTS OF SIGN INTERLOCK NAILING IN OPEN FRACTURES OF TIBIA KOLKATA.

Transcription

1 RESULTS OF SIGN INTERLOCK NAILING IN OPEN FRACTURES OF TIBIA A STUDY DONE AT J. N. ROY HOSPITAL KOLKATA. DISSERTATION SUBMITTED TO UNIVERSITY OF SEYCHELLES AMERICAN INSTITUTE OF MEDICINE IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE M.Ch (Orthopaedic Surgery) BY DR. MANAS SAHA CONSULTANT ORTHOPAEDIC SURGEON JULY

2 INTRODUCTION Open fracture of tibia is one of the most common injuries seen in orthopaedic practice. The appropriate treatment of open tibial fractures is one of the priority problems in modern era of traumatology. Tibia, being a subcutaneous bone, increases the chance of infection and nonunion 1. In choosing the optimal mode of treatment, one has to consider the importance of associated soft tissue injuries along with the configuration of fracture. Various modalities of treatment are practiced ranging from plaster immobilization to debridement and surgical stabilization. Immobilization, in a plaster cast,have been commonly practiced in the past but it does not always maintain the length of tibia and leaves the wound relatively inaccessible 2,3. Internal fixation with plate and screws have resulted in unacceptable rates of infection 4,5,6. External fixation, preferred by many traumatologists have the disadvantages of bulky frames, frequent pin track infections, nonunions and malunions 4,7. Intramedullary nails such as Lottes & Ender nails, introduced without reaming, have been used successfully in treatment of open tibial fractures and have been associated with low rates of post operative infection. However in cases of comminuted fractures, there was shortening or displacement of such fractures around these small nails 7,8,9,10. The locking of intramedullary nails decreased the prevalence of malunion in comminuted fractures. Until recently, majority of the interlocking intramedullary nails involved reaming which destroys the endosteal blood supply 11 and causes thermal necrosis of tibia 12. 2

3 The rate of infection after treatment of open tibial fractures with intramedullary nailing with reaming have been relatively high causing most surgeons to discourage its use for Type III open tibial fractures 8,13. Early debridement and unreamed interlock nailing have emerged as an important modality for management of open fractures of tibia 14. However, use of smaller size of unreamed tibial nails have been associated with increased rate of nail or screw breakage 15,16. We used SIGN interlocking nails which has a special design and unique locking mechanism 17 for treatment of open tibial fractures. This study was done to evaluate whether appropriate sized solid SIGN unreamed interlocking nails could provide a reliable option for treatment of open fractures of tibia. 3

4 MATERIALS AND METHODS : This prospective study was done at J. N. Roy Hospital, Kolkata between January 2006 and December All patients were admitted through OPD and Emergency department of this institute. 5 patients with 6 fractures were excluded because of inadequate follow up 1 patient died from multiple injuries and 4 others were lost to follow up. Patients : A total 25 patients with 25 open tibial fractures were taken up for study. Only salvageable limbs with Gustilo Type I, II,III A or III B 18 open tibial fractures and a wound which could be rendered clean before insertion of the nail were included in this study. Limbs with open fractures with vascular or tibial nerve injury or an unhealthy wound that was not suitable for flap coverage were considered unsalvageable. All fractures that were located at least 3 cms. from the ankle and knee joint in tibia and in which the medullary canal was large enough to accept the SIGN nail without reaming were selected for the study. Out of the 25 patients selected, there were 20 males and 5 females. The ages of the patients were from 17 years to 72 years (average 41.1 years.).there were 14 right sided and 11 left sided involvements. For descriptive purposes, the tibia was divided into 4 zones Zone A (upper third), Zone B (middle third), Zone C (junction of middle and lower third) and Zone D (lower third). There were 2 fractures in Zone A, 16 fractures in Zone B, 6 fractures in Zone C and 1 fracture in Zone D. 4

5 Most of these fractures were caused by high energy trauma 8 patients had history of direct trauma and in the remaining 17 patients due to road traffic accidents. The soft tissue injuries were classified according to the system of Gustilo et al. 13 patients with Type I, 6 patients with Type II, 5 patients with Type IIIA and 1 patient with Type III B injuries were selected in our study. The morphology of tibial fracture was classified as transverse, spiral, comminuted and short oblique fractures. There were 7 transverse, 1 spiral, 10 comminuted and 7 short oblique fractures (Table - I). 6 patients had other associated injuries and 1 patient had ipsilateral medial malleolar fracture. Morphology of Fracture No. of patients (Gustilo Type) I II III Transverse Fracture Short Oblique Fracture Comminuted Fracture Spiral Fracture Table I : Morphology of Fracture versus Gustilo Type of Injury SIGN Instrumentation : The Surgical Implant Generation Network (SIGN) nails are solid, stainless steel nails which have slots rather than holes to accommodate the interlocking screws. The nail is straight but has a 9 0 and apex posterior bend at proximal and distal end respectively. 5

6 SIGN nails are available in length ranging from 280 mm to 420 mm with gradual increases of 20mm in length (i.e. 280mm, 300 mm, 320 mm,..,420 mm) and diameter of 8 mm to 12 mm with gradual increase of 1 mm (i.e. 8 mm, 9 mm, 10 mm, 11 mm and 12 mm). Each nail has 2 distal dynamic locking slots and 2 proximal locking slots one static (most proximal) and one dynamic. This allows micro motion and dynamization at fracture site upon weight bearing and at the same time prevents migration of the nail (static slot). The locking screws are self tapping (3.5 mm. in diameter) with a larger threaded screw head (6.3 mm. in diameter) and a tapering conical tip that is unique to the system. The threaded screw head allows better purchase in an osteoporotic bone. The screws are available in sizes from 25 mm to 75 mm with augments of 5 mm length (i.e. 25 mm, 30 mm, 35 mm,.,75 mm). Other SIGN equipments (Fig. 1) necessary for use of SIGN nails are L-Handle Locking Bolt Target Arm (Proximal and Distal) Cap Screws for locking of distal arm Shoulder Cap Screw for locking of proximal arm Combination Hex Wrench Cannula Alignment Pin Drill guides (one for large and one for small drill bits) Drill Bits (large 6.3 mm for near cortex and small 3.5 mm for both near and far cortex) 6

7 Screw Caddy and SIGN Interlocking screw assortment SIGN IM Nail assortment Hex Screw Driver 3.5 mm Extractor / Compressor Set (Extractor Rod Connector, Extractor / Compressor Rod, Slap Hammer Weight Slot Finders (Cannulated, Solid and Curved 11 mm wrench Tissue Protector Depth Gauge Step Drill Screw Hole Broach Figure 1 : SIGN Instruments with SIGN Nail and Screws. 7

8 METHODS : All patients were primarily resuscitated and evaluated for other associated injuries. Routine wound swab was sent for Culture Sensitivity report. The patients were routinely given second generation Cephalosporin - Injection Cefuroxime (1.5 gm intravenous twice daily) and Aminoglycoside Injection Amikacin (500 mg intravenous twice daily) routinely. 17 patients were operated within 24 hrs. of injury, 7 patients were operated 5 7 days after injury and 1 patient after 3 weeks of injury. Positioning of Patients : The patients were placed supine on the table (Fig. 2). No fracture table was used for reduction. After administration of anesthesia (preferably spinal anesthesia), the wound was debrided and irrigated copiously by pulsatile lavage. About 3 to 6 litres of normal saline was used in every case. Dead muscles, devitalized soft tissues were debrided. Foreign bodies and small bony fragments without muscle attachments were removed and irrigation was continued until the wound looked relatively clean. High pressure irrigation was avoided and care was taken to avoid soft tissue stripping of fracture fragments. 8

9 Figure 2 : Positioning of patient on table Incision and Proximal Tibial entry : There are different recommendations regarding the entry point in bone. A trans patellar tendon approach and medial para patellar entry are most commonly used. A trans patellar tendon approach is preferred as it carries no increased risk of anterior knee pain 19,20. A central longitudinal incision through the patellar tendon allows a predictable and accurate placement of bone entrance where image intensifier is not used. We used patellar tendon splitting approach in 20 cases and the medial para patellar incision in 5 cases. The patellar tendon was palpated with knee in flexion and incision given (Fig- 3). A curved awl directed anteriorly was used to mark and create the entry point of nail anterior to the articular surface (Fig. 4). Care was taken not to place the entry too anteriorly or to enter the pad of fat 21,22 (Fig. 5). With several passes of the awl an adequate entry point was made for nail insertion. 9

10 Figure 3 Figure 4 Figure 5 Nail Insertion : After proper reduction, a bulb tipped guide wire was passed in the medullary canal until it reached the physeal scar or subchondral bone near the ankle joint. Manual reamers were now passed over the guide wire in the medullary canal of gradually increasing diameter without reaming until it snugly fitted in the medullary canal at isthmus of tibia. This was checked by fluoroscopy. This was done to determine the length and diameter of the planned nail to be introduced (Fig. 6). This was cross checked with the preoperative assessment of the nail length and diameter which was done from preoperative radiographs at 120% magnification. The nail length can also be measured anthropometrically from tibial tuberosity to medial malleolus or joint line to medial malleolus of the healthy (uninjured) limb. The knee joint to ankle joint line length less 20 mm. is the most reliable and has shown best correlation with ideal nail length 23. We used SIGN nails ranging from 280 mm to 360 mm in length (mainly 300 and 320 mm) and diameter 8 mm to 10 mm (mainly 8 mm and 9 mm). 10

11 The chosen nail was then attached to the target arm and L-handle by locking bolts and the target arm was adjusted and checked for distal locking slots. The target arm was then removed and the locking bolt and the L-handle were used to introduce the nail (Fig. 7). The nail was gradually introduced in the medullary canal by pressure from the surgeon or light taps using the mallet with the limb flexed and kept in a Figure of Four position. Closed reduction was possible in all cases. The surgeon s tactile senses guided the placement of the nail across the fracture site in absence of fluoroscopy. The ring on the stem tube of L-handle decided the depth of nail insertion in absence of fluoroscopy. Where fluoroscopy was available, the accuracy of reduction and entry and placement of nail was checked fluoroscopically. Figure : 6 Figure : 7 Distal Interlocking : The target arm was reattached to nail and alignment pin used to mark the location of skin incision. Incision was given and soft tissues dissected up to bone. Care was taken to avoid injury to saphenous vein and nerve (Fig. 8). The cannula was inserted through the target arm to rest on the bone. A small drill bit was used to drill the near cortex through the cannula. The cannula was changed and a large drill bit or step drill was used to enlarge the hole to 11

12 accommodate the large slot finder and screw head. Drilling was stopped when the step drill engaged in the slot of the nail (Fig. 9). Figure : 8 Figure : 9 A solid slot finder was inserted in the cannula and slot in the nail was checked (Fig. 10). This was changed to a cannulated slot finder and the smaller drill bit was placed through it to drill the far cortex (Fig. 11). Now the depth gauge was introduced through the cannulated slot finder to measure the screw length. 2-3 mm longer screws were used to lock the nails through the cannula so that the proximal ends of the screw heads could be left slightly prominent to facilitate removal at a later date (Fig. 12). The alignment pin was placed through the hex head of the inserted screw and the target arm aligned for placement of the next distal locking screws if required (Fig. 13). The number of distal locking screws used depended on the stability of the fracture, 12

13 distance of the slot from fracture site and location of fracture. Figure : 10 Figure : 11 Figure : 12 Figure : 13 Compression of Fracture : 13

14 After placing the distal interlocking screws, fracture was checked under fluoroscope and decided whether compression was necessary. In cases, where compression was necessary it was achieved by attaching the extractor/ compressor rod containing the weight and back slapping the fracture. (Fig. 14) Figure : 14 Proximal Interlocking : The target arm was replaced and the same procedure was followed as for distal interlocking to lock the nail proximally (Fig. 15). The placement of 2 screws in proximal tibia is recommended. However, clinical results have shown 1 locking screw to be sufficient in most cases 24. In our series, we used 2 proximal and 2 distal locking screws in 8 cases, 1 proximal and 2 distal locking screw in 5cases, 2 proximal and 1 distal locking screw in 4 cases and only 1 proximal and 1 distal locking screw in 8 cases. The proximal screws used were 35 mm. to 50 mm. in length (mainly 40 mm. and 45 mm. length) and distal screws were 25 mm. to 45 mm. in length (mainly 35 mm. and 40 mm. in length). As SIGN nail has unique locking mechanism it can be used at Centres where fluoroscopy is not available 25. Initially, cases were done under C-arm guidance. Later, 8 cases were done without C-arm guidance (Fig. 16). 14

15 Figure : 15 GUSTILO TYPE I INJURY WOUND DEBRIDEMENT PROXIMAL TIBIAL ENTRY DISTAL LOCKING MEASUREMENT OF NAIL INSERTION OF NAIL DISTAL LOCKING PROXIMAL LOCKING CLINICAL PHOTO AFTER NAILING Figure 16 : Operative Technique Wound Closure: 15

16 The incision through the patellar tendon was closed first. Next the skins over the screw placement sites were closed. Lastly, wound over the fracture site was closed. Primary wound closure was done in 17 cases and delayed primary closure (within 72 hour) in 5 cases. 2 cases required secondary skin grafting and one patient was treated with a fasciocutaneous muscle flap (Table - II and Fig. 17). Modes of Wound Closure No. of patients (Gustilo Type) I II IIIA IIIB Primary Closure Delayed Primary Closure Split Skin Graft Flap Coverage Table II : Wound Closure versus Gustilo Type of Injury Figure 17 : Primary closure, split skin graft and flap coverage The operating time was 45 minutes to 90 minutes (average 60 mins). The operating time was less with Gustilo Type I injuries, simple fracture pattern, and fresh fractures. The operating time slightly increased when cases were done without fluoroscopy assistance. Post Operative Regimen 26 : 16

17 After operation, limb was kept elevated over pillows for 24 hours. Parenteral antibiotics were continued for 5 days followed by oral antibiotics until stitch removal or wound healing. Quadriceps exercises and ankle exercises were encouraged after subsidence of pain (2-3 days). Active knee bending allowed after stitch removal (12-14 days). Partial weight bearing was allowed when the patient could perform active straight leg raising (SLR) (average 6 wks). Full weight bearing was allowed only after evidence of clinical and radiological union (average wks.). After discharge, patients were followed up at intervals of 2 weeks for first 2 months and thereafter at intervals of 4 weeks. Union was evaluated clinically and radiologically. Knee and ankle function and wound healing was also evaluated. OUTCOMES : The follow up period was 8-30 months (average 20 months). The fractures united in all patients (Fig. 18,19,20,21,22 & 23) except in 1 patient who showed delayed union. No significant difference was noted on quality of fracture union in patients when operation was done within 24 hours or after 5 7 days. 1 patient had valgus malunion and 1 patient had limb shortening of 2.5 cms. Culture Sensitivity swab taken on Day 1/ Admission showed Staphylococcus aureus in 8 patients and Escherichia coli in 1 patient and no growth in 16 patients. Out of these 9 patients, 1 patient developed superficial infection and 1 patient had deep infection. Wound healed uneventfully within 2 weeks in all patients except these 2 patients who had infection. So, Cefuroxime and Amikacin proved to be an effective antibiotic regimen in 17

18 treatment of open fractures of tibia. All patients recovered almost full knee and ankle motion except 1 patient who had restriction of knee motion (Table III). Overall, 92 per cent good to excellent functional results were achieved by using unreamed SIGN Interlock nail fixation for open fractures of tibia. Complications No. of patients (Gustilo Type) I II IIIA IIIB Early Superficial Infection Deep Infection Knee Stiffness Delayed Union Malunion (Valgus) Shortening of Limb (>2 cms) Implant Failure Table III : Complications versus Gustilo Type of Injury Figure 18 : Gustilo Type II injury treated by SIGN nail. 18

19 Figure 19 : Gustilo Type III A injury treated by SIGN nail. PREOP POSTOP FOLLOW UP 6 MTHS Figure 20 : Clinico-radiological follow up of Gustilo Type I injury at 6 months PREOP POSTOP FOLLOW UP 1 YEAR Figure 21 : Clinico-radiological follow up of Gustilo Type I injury at 1 yr. 19

20 PRE OP POST OP PRE OP F.U. 18 MTHS Figure 22 : Clinico-radiological follow up of Gustilo type II injury at 18 months PRE OP POST OP FOLLOW UP 2 YRS Figure 23 : Clinico-radiological follow up of Gustilo Type III injury at 2 yrs. 20

21 ANALYSIS : Union was defined as the presence of bridging callus on two radiographic views and the ability of the patient to bear full weight on the injured limb, if other injuries allowed. All fractures united uneventfully in our series except in 1 patient who showed delayed union. The time of fracture union was 13 weeks 20 weeks (average wks.) It is similar to the study of Court Brown and Coworkers 27 who reported union time as 16.9 weeks, and Bostman and Hanninen who reported 15.3 weeks of union time 28. The patient who showed delayed union had Gustilo Type IIIA injury with comminuted fracture pattern and also deep infection. Fracture union was achieved in this patient at 32 weeks. 21

22 Malunion was defined as varus or valgus angulation of more than 5 degrees, antero-posterior angulation of more than 10 degrees or shortening of more than two centimeters. In our series, 1 patient had valgus malunion and 1 patient had shortening of 2.5 cms. The patient who had valgus malunion had Gustilo Type III A injury with transverse fracture in the proximal third of tibia. We had to use a para patellar approach for nail insertion in this patient as the skin over the patellar tendon was unhealthy. The patient who had limb shortening of 2.5 cms. had Gustilo type IIIB injury with highly comminuted fracture in middle third tibia. In our series, 2 patients with Type III A injury developed infection. No infection was noted in patients with Gustilo type I and Type II injuries. 1 patient had superficial infection with Staphylococcus aureus which healed at 2 weeks with parenteral antibiotics and one patient had deep infection with Escherichia coli He was managed with irrigation and debridement at 3 weeks and antibiotics according to Culture Sensitivity report. He was on parenteral antibiotics for 6 weeks followed by oral antibiotics for another 1 month by which time the infection subsided. Whittle et al reported infection rate of 8% in open tibial diaphyseal fractures fixed with interlocking nail without reaming 29. This is also comparable to the study done by Santoro et.al 30 and Melchar Collegue 31 who reported an infection rate of 0% - 8% with unreamed interlocking nails in their series. All patients recovered almost full knee and ankle motion except 1 patient who had restriction of knee motion. This patient had Gustilo Type IIIA injury and had valgus malunion. All patients except one nearly achieved 130 degrees knee flexion with 15 degree dorsiflexion and 30 22

23 degree plantar flexion of ankle. Final functional outcome was based on modified Ketenjian s criteria 32. Results were good to excellent in 23 patients (92%), fair in one patient (4%) who had Gustilo Type IIIA injury with valgus malunion and deep infection and poor in one patient (4%) who had Gustilo Type IIIB injury with limb shortening of 2.5 centimeters. There was no incidence of implant failure in our series. This may be attributed to the special design of SIGN nail solid nails with locking slots and specially designed locking screws. Results (Modified Ketenjian s Criteria) Excellent No notable abnormality Good Occasional pain with prolonged use Joint motion 75% of normal Trivial swelling Normal gait Fair Pain with ordinary activity Joint motion 50% of normal Small amount of swelling Slight limp No. of patients (Gustilo Type) (%) I II IIIA IIIB

24 Poor Constant pain Joint motion 50% of normal Any visible deformity Limp, gait on cane or crutches Table IV : Final Functional Results versus Gustilo Type of Injury DISCUSSION : The major factors affecting the prognosis of open tibial fractures after high energy trauma are the severity of soft tissue injuries, degree of contamination, fracture configuration, and the extent of comminution 33. Recent improvements in wound-coverage techniques and fixation devices have decreased the prevalence of complications, but the optimum management of open fractures of tibia is still evolving. The plaster cast treatment is associated with high incidence of deep infection and malunion 2. Nicoll reported a rate of infection of 15 percent after treatment of 144 open tibial fractures with cast. More recently, Puno et al. reported a 12.5 percent rate of malunion in a series of twenty-four open tibial fractures treated with a plaster cast. Immobilization in a plaster cast, therefore, should be reserved for stable fractures with minimum injury to the soft tissues. 24

25 The external fixators, being versatile and able to facilitate early soft-tissue healing, had been extensively used in the past. They provide rigid fixation with relatively low rate of deep infection. However, it has been associated with a high incidence of pin tract infection, malunion, bulky appearance and loss of reduction after removal 34. Bach and Hansen found 13 percent rate of wound infection, 10 percent rate of pin tract infection, and 10 percent rate of malunion in their series. Application of a plate provides rigid internal fixation of an unstable fracture and reduces the problem of nonunion. However, the stripping of soft tissues required for application of a plate has led to an unacceptable rate of infection in patients who have open tibial fracture. Smith found an 18 percent rate of infection and Ruedi et al. reported a rate of 11 percent in their large series of open tibial fractures treated with a plate. Interlocking intramedullary nailing with reaming solves the problem of malunion because it provides the ability to control length, angulation and rotation. Reaming, however, destroys the endosteal blood supply further devascularizing the already compromised bone 11. The unreamed tibial nailing is reported to have definite advantages over the reamed nailing 29. Unreamed nailing in experimental studies has been found to cause less reduction in cortical circulation as compared to reaming of the medullary canal 35 Klein et al. 36 reported 31 percent reduction of cortical circulation using unreamed nail as compared to 71 percent reduction after reaming. Reaming of open fractures has been found to spread the contamination from open wound along the medullary cavity and to strip small fragments of bone from their soft tissue attachments 37. Reaming has also been reported to slow the revascularization and delay osseous union 11,29. The surface area of a hollow nail is 2 times that of a solid nail and so it contains more dead space and therefore more susceptible to infection 38. Cortical necrosis is less likely to occur with a loosely fitted intramedullary nail than a snugly fitted reamed nail 39. In addition, smooth surface of solid nail may decrease the susceptibility of infection by decreasing the adherence of bacteria 40. In our series, Gustilo Type III A injury was associated with deep infection and valgus malunion. Various series have reported 2% to 6% incidence of deep 25

26 infection in Gustilo Type III injuries 41,42. So careful selection of patients for using unreamed SIGN nail in Gustilo Type IIIA injuries is recommended. As only one patient with Gustilo Type IIIB injury was treated in our series and this patient had complication of shortening it would be unfair to comment on the use of SIGN nails for Gustilo Type III B injuries without further study. CONCLUSIONS AND RECOMMENDATIONS : Solid unreamed SIGN nails provides a stable fixation, preserves the soft tissue sleeve around the fracture site, maintains cortical blood flow and allows early motion of adjacent joints. The unique design of this nail and screws is associated with low rate of implant failure and its unique locking mechanism allows proximal and distal locking even without fluoroscopic guidance. The SIGN nail procedure is simple, easy, fast and easily reproducible by an average surgeon. Other potential advantages include shorter operative time, less blood loss, early mobilization, shorter hospital stay and early weight bearing. Adequacy of wound irrigation, debridement and soft tissue coverage is very important in prevention of infection in open fractures of tibia. As SIGN 26

27 nail has a unique technique in locking mechanism, so the nail can also be used at peripheral centers where fluoroscope is not available. From our study it can be concluded that solid, unreamed, SIGN interlock nailing system may be considered as a suitable option for treatment of open fractures of tibia. REFERENCES : 1. Kristian D. Kristansen. Tibial shaft fractures : Frequency of local complication in tibial shaft fractures treated by internal compression osteosynthesis : Acta Orthopaedia. 1979, Vol. No. 5 : Brown P. W., and Urban, J. G. : Early weight-bearing treatment of open fractures of the tibia. An end-result study of sixty-three cases. J. Bone and Joint Surg. 51-A: Jan Puno, R. M. ; Teynor, J. T.Nagano, Junji and Gustilo, R. B. : Critical analysis of results of treatment of 201 tibial shaft fractures. Clin. Orthop., 212: , Bach, A. W. and Hansen, S. T., Jr. : Plates versus external fixation in severe open tibial shaft fractures. A randomized trial. Clin. Orthop. 241:89-94,

28 5. Ruedi, T.; Webb, J. K.; and Algower, M.: Experience with the dynamic compression plate (DCP) in 418 recent fractures of the tibial shaft. Injury, 7: , Smith, J.E.M. : Results of early and delayed internal fixation for tibial shaft fractures. A review of 470 fractures. J. Bone and Joint Surg. 56-B(3): , Holbrook, J.L. : Swiontkowski, M.F. ; and Sanders, Roy : Treatment of open fractures of the tibial shaft : Ender nailing versus external fixation. A randomized, prospective comparison. J. Bone and Joint Surg. 71-A: , Sept Klemm, K.W., and Borner, Martin : Interlocking nailing of complex fractures of the femur and tibia. Clin. Orthop., 212 : , Swanson, T.V.; Spiegel, J.D.; Sutherland, T.B.; Bray, T.J.; and Chapman, M.W. : A prospective comparative study of the Lottes nail versus external fixation in 100 open tibia fractures. Orthop. Trans. 14: , Wiss, D. A. : Flexible medullary nailing of acute tibial shaft fractures. Clin. Orthop., 212: , Rhinelander, F.W.: Tibial blood supply in relation to fracture healing. Clin. Orthop., 105:34-81, Leuning M and Hertel R. Thermal necrosis after tibial remaining for intramedullary nail fixation. J Bone Joint Surg (Br) 1996; 8-B Bone, L.B., and Johnson, K.D. : Treatment of tibial fractures by reaming and intramedullary nailing. J. Bone and Joint Surg., 68-A: , July D Joshi, A Ahmed, L Krishna, Y Lal : Unreamed interlocking nailing in open fractures of tibia. Journal of Orthopaedic Surgery 2004:12(2): Whittle A. William Wester and Russel A. Fatigue failure in small diameter tibial nails. Clin Orthop 1995; 315: Christian Krettek, Peters Chandelmaier and Herald Tscherne. Non-reamed interlocking nailing of closed tibial fractures with severe soft tissue injury. Clin Orthop 1995; 315: Feibel, Robert J. MD; Zirkle, Lewis G. Jr MD.: Use of Interlocking Intramedullary Tibial Nails in Developing Countries. Techniques in Orthopaedics: December Volume 24 - Issue 4 - pp

29 18. Gustilo, R. B.; Mendoza, R. M.; and Williams, D.N.: Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J. Trauma, 24: , Toivanen JA, Väistö O, Kannus P, et al. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: a prospective, randomized study comparing two different nail-insertion techniques. J Bone Joint Surg Am 2002;84-A: Väistö O, Toivanen J, Kannus P, et al. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft: an eight-year follow-up of a prospective, randomized study comparing two different nail-insertion techniques. J Trauma 2008;64: Weil YA, Gardner MJ, Boraiah S, et al. Anterior knee pain following lateral parapatellar approach for tibial nailing. Arch Orthop Trauma Surg 2009;129: Weninger P, Schultz A, Traxler H, et al. Anatomical assessment of the Hoffa fat pad during insertion of a tibial inramedullary nail-comparison of three surgical approaches. J Trauma 2009;66: Venkateswaran B, Warner RM, Hunt N, et al. An easy and accurate preoperative method for determining tibial nail lengths. Injury 2005;36: Griffin LV, Harris RM, Zubak JJ. Fatigue strength of common tibial intramedullary nail distal locking screws. J Orthop Surg Res 2009;4: Innocent C. Ikem, Johnson D. Ogunlusi, and Henry R. Ine Achieving interlocking nails without using an image intensifier. Int Orthop August; 31(4): Dr. M. Saha, Dr. A. N. Mukherjee : SIGN interlock nailing in open fractures of tibia Clinical Experience. Journal of WBOA, Vol-23, No.-7, July Court-Brown CM, Wili E., Christie, J., Mc Queen MM. Reamed on unreamed nailing for closed tibial fractures. J Bone Joint Surg 1996; 78-B : Bostmann, O., and Hanninen, A. Tibial shaft fractures caused by indirect violence. Acta. Orthop. Scand. 1982; 53: Whittle, A.P., Russel, T.A., Taylor, J.C. and Lavelle, D. G. Treatment of open fracturesof the tibial shaft with use of interlocking nailing without reaming. J Bone Joint Surg 1992; 74-A :

30 30. Santoro, V., Henby, M., Benirschke, S. and Mayo, K. Prospective comparison of unreamed interlocking intramedullary nails versus half pin external fixation in open tibial fractures. J. Orthop. Trauma. 1991, 5 : Leutenegger, A. and Ruedi, T. Tibial fracture treated with the AO tibial nail. Injury : Yokoyama K, Shindo M, Itoman M, Yamamoto M, Sasamoto N. Immediate internal fixation for open fractures of the long bones of the upper and lower extremities. J trauma 1994;37: Hoaglund FT, States JD, Factors influencing the rate of healing in tibial shaft fractures. Surg Gynecol Obstet 1967;124: Green SA. Complications of external skeletal fixation. Clin Orthop 1983;180: Rhinelander FW. Effects of medullary nailing on the normal blood supply of diaphyseal cortex. AAOS-Instructional course lectures. St Louis; C.V. Mosby Co; Klein MP, Rahn BA, Frigg R, Kessler S, Perren SM. Reaming versus nonreaming in mdullary nailing: interference with cortical circulation of the canine tibia. Arch Orthop Trauma Surg 1990;109: Kessler SB, Hallfeldt KK, Perren SM, Schweiberer L. The effects of reaming and intramedullary nailing on fracture healing. Klin Orthop. 1986;212: Melcher GA, Claudi B, Schlegel U, Perren SM, Printzen G, Munzinger J. Influence of type of medullary nail on the development of local infection. An experimental study of solid and slotted nails in rabbits. J Bone Joint Surg Br 1994;76: Sargeant ID, Lovell M, Casserley H, Green AD. The AO unreamed tibial nail:a 14 month follow-up of the 1992 TT experience. Injury 1994;25: Cordero J, Munuera L, Folgueira MD. Influence of metal implants on infection. An experimental study in rabbits. J Bone Joint Surg Br 1994;76: Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones; retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:

31 42. Singer RW, Kellam JF. Open tibial diaphyseal fractures. Results of unreamed locked intramedullary nailing. Clin Orthop 1995;315: