Intramedullary nailing without interlocking screws for femoral and tibial shaft fractures

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1 DOI /s Trauma Surgery Intramedullary nailing without interlocking screws for femoral and tibial shaft fractures Dieuwertje L. Kreb Taco J. Blokhuis Karlijn J. P. van Wessem Mike Bemelman Koen W. W. Lansink Luke P. H. Leenen Received: 12 November 2012 Springer-Verlag Berlin Heidelberg 2013 Abstract Background Intramedullary fixation is the treatment of choice for diaphyseal fractures of the femur and tibia. Locking the implant can sometimes be cumbersome and time consuming. In our institution, fractures with axial and rotational stability are treated with intramedullary nailing without interlocking. Methods All consecutive patients presented in the University Medical Center Utrecht from October 2003 to August 2009 with acute traumatic diaphyseal fractures of the tibia or femur that were considered axial and rotational stable were included. They underwent internal fixation using intramedullary nails without interlocking. Patient records were evaluated for duration of surgery, perioperative complications, consolidation time and re-operations. Results Twenty-nine long bone fractures were treated in 27 patients: 20 men and 7 women, with an average age of 28.9 years (range ). There were 12 femoral fractures and 17 tibial fractures. Sixteen fractures were closed and 13 were open (10 Gustilo 1, 3 Gustilo 2). The mean operating time was 43 min (range min) for tibial fractures and 55 min (range min) for femoral fractures. Postoperative complications occurred in six patients. Two patients (three fractures) were lost to follow-up. Healing occurred in 25 of the 26 remaining fractures (96 %) without additional interventions. One tibia was secondarily converted to a standard locked nail because of axial D. L. Kreb (*) T. J. Blokhuis K. J. P. van Wessem M. Bemelman K. W. W. Lansink L. P. H. Leenen Department of Surgery, University Medical Center Utrecht (UMCU), HP G04.228, P.O. Box 85500, 3508 GA Utrecht, The Netherlands dl.tielgroenestege@gmail.com and rotational instability. All patients returned to their preinjury level of activity. Conclusion The use of intramedullary nailing without interlocking is associated with minimal complications in selected fractures. The advantages include a short operating time and the simplicity of its application. Keywords Intramedullary nailing Diaphyseal fractures Femur Tibia Introduction Interlocked intramedullary fixation is considered the treatment of choice for diaphyseal fractures of the femur and tibia [1 3]. It allows early weight bearing and quick rehabilitation, combined with a good healing rate and a low incidence of complications. When using an interlocked nail, proximal and distal locking screws are used to maintain length and rotational stability. Insertion of the distal locking screws often turns out to be the most demanding step of the procedure. Different techniques such as targeting devices mounted onto the nail or onto the image intensifier have been proposed without success so far, and free-hand techniques are used for distal locking nowadays by most surgeons [4]. As a consequence, the placement of the locking screws is associated with significant radiation exposure and a longer operating time [5, 6]. Nerve damage causing numbness and pain as a result of the locking screws has been reported in the literature with an incidence between 3.7 and 30 % [7 10]. In our institution, shaft fractures of the femur and tibia with an intrinsic axial and rotational stability after introducing an intramedullary nail are treated without interlocking

2 screws. In this report the clinical results and feasibility of the technique are described. Patients and methods A retrospective analysis was performed of all patients treated between October 2003 and August 2009 in the University Medical Center Utrecht, a level-1 trauma center. The indication for an intramedullary nail without interlocking was a traumatic diaphyseal fracture of the tibia or femur that was considered to have axial and rotational stability after reduction of the fracture and introduction of the nail. To ensure adequate stability after fixation with an intramedullary nail, fractures of the proximal and distal third of the femur or tibia were excluded. Stability was assessed by physical examination by the operating surgeon under constant fluoroscopic control. Only if no movement at the fracture site could be demonstrated under fluoroscopic control while exerting considerable rotational force, rotational stability was assumed. The amount of rotational force used to assess rotational stability was left at the discretion of the senior operating surgeon. Vertical stability was assessed on configuration of the fracture after reduction, in general meaning that bone contact was present on at least three of four cortices on anteroposterior and lateral X-rays. The fractures were classified according to the AO system [11] and open fractures were also classified using the Gustilo Anderson classification [12]. Patient records were evaluated for duration of surgery, perioperative complications, healing time and re-interventions. Absence of localized tenderness and ability to bear weight without pain were considered clinical criteria for union, radiographic criteria of union being continuity in at least in three cortices in both AP and lateral views. Time to healing was defined as the first point at which full weight bearing was possible without the use of walking aids. Surgical technique All patients were operated in supine position on a radiolucent operating table without a traction device. All patients received 2 g of Cefacidal pre-operatively. Patients with an open fracture were also administered Gentamicin (1 dose of 4 mg/kg body weight) pre-operatively and these antibiotics were continued for 72 h after surgery. Fracture reduction and alignment were obtained using standard techniques under an image intensifier. The intramedullary nails used (UTN, ETN, UFN) were obtained from Synthes BV, Zeist, the Netherlands. During the study period, unreamed nails were used for fixation of diaphyseal fractures of the femur and tibia, unless the diameter of the intramedullary canal was too narrow to fit the nail. In these cases the intramedullary canal was reamed up to 1 mm larger than the diameter of the nail. After reduction and nail insertion, the operating surgeon decided whether a fracture was axial and rotationally stable based on fluoroscopic as well as physical assessment. As described above, this was assessed by the senior operating surgeon under constant fluoroscopic control while exerting considerable rotational force. If no movement at the fracture site could be demonstrated, rotational stability was assumed. Fractures were considered vertically stable if bone contact was present on at least three of four cortices on anteroposterior and lateral X-rays. After surgery, weight bearing was allowed as tolerated as soon as the patient had regained limb control. Results Twenty-nine long bone fractures were treated in 27 patients: 20 men and 7 women, with an average age of 28.9 years (range ). Traffic accidents were the leading cause of fractures: ten fractures were due to motor vehicle accidents and in nine cases either pedestrians or cyclists were hit by a car. The remaining fractures were due to sports (4), a fall (3) or a gunshot wound (1). There were twelve femoral fractures (AO A1 3 and 2 32.B2) and 17 tibial fractures (AO A1 3 and 2 42.B2). All fractures were midshaft fractures. Of these 29 fractures, 16 were closed and 13 were open (Gustilo Anderson: 10 grade 1, 3 grade 2). Patient and fracture characteristics are summarized in Tables 1 and 2. Half of the patients with a femoral fracture had additional injuries, whereas the majority of the tibial fractures were isolated injuries (12/17 patients). Table 1 Patient characteristics No. of patients 27 No. of fractures 29 Male:female 20:7 Age (years) 28.9 ( ) Table 2 AO classification of fractures Femur, AO 32 Tibia, AO 42 A1 1 A1 1 A2 3 A2 5 A3 6 A3 9 B1 0 B1 0 B2 2 B2 2 B3 0 B3 0

3 Fig. 1 AP (left) and lateral (right) views preoperative (a), direct postoperative (b), after 2 months (c) and after 9 months (d) of an AO 42-A2 fracture, treated with an intramedullary nail without interlocking A little over half of the fractures were transverse fractures and in most fractures a notch or spike was present. In only four fractures reaming was required to fit the nail. After reduction of the fracture, axial stability and rotational stability were ensured by these fracture appearances. In typical cases both fracture ends would interlock anatomically upon reduction. A typical example of a tibia fracture is shown in Fig. 1. Intramedullary nailing was performed within 24 h in 26/29 fractures. One patient who suffered a tibia shaft fracture elsewhere preferred operative treatment in our institution and she was treated with an intramedullary nail 12 days after the initial trauma. One patient with a Gustilo Anderson type 2 fractured tibia was first treated with an external fixator, which was changed for an intramedullary nail after 6 days. One critically injured patient who suffered severe lung contusion and a subdural hematoma, for which he required a decompressive craniectomy, was treated with an intramedullary nail of his tibial fracture 5 days after the initial trauma. The mean duration of the operation was 43 min (range min) for tibial fractures and 55 min (range min) for femoral fractures. Closed reduction was achieved in 24 fractures. The Unreamed Femur Nail (UFN, Synthes BV, Zeist, the Netherlands) was used for all femoral fractures (Ø 9 mm: N = 9, Ø 10 mm: N = 3). Thirteen tibial fractures were stabilized with an Unreamed Tibia Nail (UTN, Synthes BV, Zeist, the Netherlands Ø 8 mm: N = 8, Ø 9 mm: N = 5) and an Expert Tibia Nail (ETN, Synthes BV, Zeist, the Netherlands Ø 8 mm) was used in the remaining four. In all open fractures, the wound could be closed primarily after thorough debridement. The mean hospital stay was 10 days (range 3 50 days). Early postoperative complications occurred in six patients (22 %). Three developed a compartment syndrome requiring fasciotomy, one of which was carried out immediately after insertion of the nail. Two patients developed pneumonia and one developed respiratory distress due to fat embolism. There were no iatrogenic neurovascular incidents. Weight bearing was allowed in 19 of 27 patients immediately after surgery. In the remaining eight patients, weight bearing was not possible due to other injuries. Two patients (three fractures) were lost to follow-up, which leaves 26 fractures in 25 patients for long-term follow-up. Healing occurred in 25 of the 26 fractures (96 %) without additional interventions. The mean healing time was 12.2 ± 6.5 weeks for femoral fractures and 14.2 ± 8.8 weeks for tibial fractures, which meant that full weight bearing was possible without the use of walking aids. There was a delayed union in one tibial fracture, with

4 Table 3 Results Mean operation time Femur 55 min (47 150) Tibia 43 min (18 68) Mean hospital stay 10 days (3 50) Complications Compartment syndrome 3 patients (11.1 %) Pneumonia 2 patients (7.4 %) Fat embolism 1 patient (3.7 %) Mean healing time Femur 12.2 weeks ( ) Tibia 14.2 weeks ( ) Re-interventions Secondary locking 1 patient (3.7 %) Nail exchange 1 patient (3.7 %) Nail removal 7 patients (25.9 %) 31 weeks to consolidation. We did not observe any malunion or rotational malalignment. All patients returned to their pre-injury level of activity. One tibial fracture was converted to a standard locked nail 18 days after the initial insertion of the intramedullary nail because of axial and rotational instability. Six months after the initial trauma, the nail was exchanged for a larger (Ø 11 mm) cannulated interlocked nail because of failure of progression of fracture healing. This was complicated by infection of the proximal interlocking screw, which was removed after 5 weeks. Further healing was uneventful. Total healing time for this patient was 38 weeks. A total of seven patients underwent nail removal: two femoral nails and five tibia nails. The two femoral nails were removed on request of the patient. Three tibia nails were removed because of anterior knee pain. In one of these patients the pain was due to secondary nail protrusion into the knee joint. In two patients nail removal resolved the complaints. Two tibia nails were removed in accordance with the patients request. In one patient this led to more knee pain postoperatively. Patient outcome and complications are summarized in Table 3. Discussion Interlocked intramedullary nailing is considered the treatment of choice for diaphyseal fractures of the lower extremity [1 3]. Interlocking screws at both ends of the nail usually are required for axial and rotational stability. Locking the implant can be cumbersome and time consuming, resulting in both a longer operating time and increased radiation exposure [5, 6]. The extra wounds necessary for the interlocking screws theoretically increase the chance of wound infection and give additional surgical scars. Moreover, using interlocking screws can cause nerve injury, the incidence of which is reported between 3.7 and 30 % [7, 8]. Some fractures require dynamization and hence a second surgical procedure. This report shows that if axial and rotational stability of a fractured bone is achieved after reduction and nail insertion, there is no need for insertion of interlocking screws. Fractures that may be considered for this type of fixation are mainly midshaft AO type A3 fractures, although A1, A2, and B2 fractures can be suitable as well, provided that they have certain fracture characteristics. In these cases a spike or a notch has to present, resulting in anatomical interlocking upon reduction to ensure stability. In case of a tibial fracture, the presence of a fibular fracture did not influence the indication for this technique. Stability of the fracture after reduction and introduction of the nail is derived from the configuration of the tibia, where anatomical interlocking of the fracture ends has to occur, and this is not influenced by the presence or absence of a fibular fracture. In the present series, healing occurred in 25 of the 26 fractures (96 %) without a secondary intervention after a mean healing time of 12.2 ± 6.5 weeks for femoral fractures and 14.2 ± 8.8 weeks for tibial fractures. We observed no malunions after consolidation. The mean operating time was 43 min (range min) for tibial fractures and 55 min (range min) for femoral fractures. This is shorter than the operating time reported in series with interlocked nails. For example, Lee et al. [13] observed a mean operating time of 78 ± 24 min for interlocked tibia nailing and femoral fractures managed with conventional interlocking nails have been found to have an average operating time of up to 3.1 ± 0.5 h [14]. Although it was not recorded in this study, the avoidance of interlocking screws theoretically decreases radiation exposure as well. The main disadvantage of not using interlocking screws is the chance of secondary displacement. In this study this occurred in one patient with an AO type B2 tibia fracture. In this case, interlocking was carried out 18 days after the initial procedure. The fracture progressed to a non-union and the nail was exchanged for a larger diameter, which was complicated by infection of the proximal interlocking screw. Eventually, the fracture healed after a total of 38 weeks. Three other B2 fractures (1 tibia and 2 femoral fractures) healed uneventfully. All other fractures were AO type A1 3. The weakness of a study such as our current one is that it was not prospectively randomized for comparison to the standard interlocking nails. Furthermore, there is a certain sample bias due to the fact that there probably have been patients who met the selection criteria for an unlocked nail, but received a standard interlocking nail instead. However,

5 we believe that our results show there is a place for the use of unlocked nails in selected fractures. The present series of unlocked nails is not unique. Unlocked nails were used at the very beginning of intramedullary nailing, but the use of interlocking screws or other methods of supplementary fixation, particularly in the presence of considerable fragmentation, was soon recognized [15]. Velazco et al. [16, 17] described their experience with the Lottes nail for both open and closed fractures, as well as non-unions. All fractures healed with a rate of infection of 3.33 % and a rate of malunion of 3.33 %. More recently, unlocked nails have also been used by Lee et al. [13]. They compared 42 patients with an unlocked nail to 40 patients with an interlocked nail. They found a shorter operating time and smaller wound size in the unlocked group and no difference in union rate, healing time and malunion rate. The unlocked patients, however, were treated postoperatively with a plaster cast for several weeks, combining the disadvantages of surgery (e.g., infection) with the disadvantages of immobilization (e.g., deep vein thrombosis). In the present study, intramedullary nailing without interlocking was used without additional stabilization methods, which led to a shorter operation time and good clinical results. Conclusion In our experience, the use of intramedullary nailing without interlocking, followed by early mobilization, is feasible in selected fractures and is associated with minimal complications. It resulted in union in 96 % of patients. No malunion or rotational malalignment was observed and all patients returned to their pre-injury level of activity. Conflict of interest The authors declare that they have no conflict of interest. References 2. Duan X, Al-Qwbani M, Zeng Y, Zhang W, Xiang Z ((2012)) Intramedullary nailing for tibial shaft fractures in adults. Cochrane Database Syst Rev 1:CD Lam SW, Teraa M, Leenen LP, van der Heijden GJ (2010) Systematic review shows lowered risk of nonunion after reamed nailing in patients with closed tibial shaft fractures. Injury 41: Whatling GM, Nokes LD (2006) Literature review of current techniques for the insertion of distal screws into intramedullary locking nails. Injury 37: Levin PE, Schoen RW, Browner BD (1987) Radiation exposure to the surgeon during closed interlocking intramedullary nailing. J Bone Joint Surg Am 69: Roux A, Bronsard N, Blanchet N, de Peretti F (2011) Can fluoroscopy radiation exposure be measured in minimally invasive trauma surgery? Orthop Traumatol Surg Res 97: Koval KJ, Clapper MF, Brumback RJ, Ellison PS Jr, Poka A, Bathon GH, Burgess AR (1991) Complications of reamed intramedullary nailing of the tibia. J Orthop Trauma 5: Wiss DA, Stetson WB (1995) Unstable fractures of the tibia treated with a reamed intramedullary interlocking nail. Clin Orthop Relat Res 315: Hems TE, Jones BG (2005) Peroneal nerve damage associated with the proximal locking screws of the AIM tibial nail. Injury 36: Drosos GI, Stavropoulos NI, Kazakos KI (2007) Peroneal nerve damage by oblique proximal locking screw in tibial fracture nailing: a new emerging complication? Arch Orthop Trauma Surg 127: Müller ME, Nazarian S, Koch P, Schatzker J, Heim U (1990) The comprehensive classification of fractures of long bones. Springer, Berlin 12. Gustilo RB, Anderson JT (1976) 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 58: Lee YS, Lo TY, Huang HL (2008) Intramedullary fixation of tibial shaft fractures: a comparison of the unlocked and interlocked nail. Int Orthop 32: Lepore L, Lepore S, Maffulli N (2003) Intramedullary nailing of the femur with an inflatable self-locking nail: comparison with locked nailing. J Orthop Sci 8: Soto-Hall R, McCloy NP (1951) Problems in intramedullary nailing of femoral fractures. Calif Med 74: Velazco A, Whitesides TE Jr, Fleming LL (1981) Fractures of the tibia treated with Lottes nail fixation. South Med J 74: Velazco A, Whitesides TE, Fleming LL (1983) Open fractures of the tibia treated with the Lottes nail. J Bone Joint Surg Am 65: Duan X, Li T, Mohammed AQ, Xiang Z (2011) Reamed intramedullary nailing versus unreamed intramedullary nailing for shaft fracture of femur: a systematic literature review. Arch Orthop Trauma Surg 131: