The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 90, Issue 8

Selected Instructional Course Lecture | August 01, 2008

Avoiding Complications in the Care of Fractures of the Tibia

Lisa K. Cannada, MD¹; Jeffrey O. Anglen, MD²; Michael T. Archdeacon, MD, MSE³; Dolfi HerscoviciJr., DO⁴; Robert F. Ostrum, MD⁵

¹ Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8883. E-mail address: lisa.cannada@utsouthwestern.edu
² Department of Orthopaedics, Indiana University School of Medicine, 541 Clinical Drive, Suite 600, Indianapolis, IN 46202-5111
³ Department of Orthopaedics, University of Cincinnati Medical Center, P.O. Box 670212, 231 Albert Sabin Way, ML 0212, Cincinnati, OH 45267
⁴ Florida Orthopaedic Institute, 13020 Telecom Parkway North, Temple Terrace, FL 33673
⁵ 3 Cooper Plaza, Suite 408, Camden, NJ 08103

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Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in February 2009 in Instructional Course Lectures, Volume 58. The complete volume can be ordered online at , or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Medtronic Sofamor Danek). Also, a commercial entity (Stryker Orthopaedics) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2008 Aug 01;90(8):1760-1768

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Look for this and other related articles in Instructional Course Lectures, Volume 58, which will be published by the American Academy of Orthopaedic Surgeons in February 2009:"Prevention of Complications After Treatment of Femoral Shaft and Distal Femoral Fractures," by Robert F. Ostrum, MD, Jeffrey O. Anglen, MD, Michael T. Archdeacon, MD, MSE, Lisa K. Cannada, MD, and Dolfi Herscovici, DOTibial fractures are the most common long-bone fractures, with the National Center for Health Statistics reporting an annual incidence of 492,000 fractures of the tibia and fibula per year in the United States¹. Fractures of the tibial shaft range from low-energy minimally displaced fractures to limb-threatening injuries with associated nerve and arterial damage and major damage to the soft-tissue envelope. Even the lower-energy tibial shaft fractures are not as benign as they seem. Common problems include deformity after intramedullary nail fixation of fractures in the proximal one-third of the tibia, infections after open fractures, and aseptic nonunions. This lecture covers these three common complications, with an emphasis on prevention, recognition, and treatment.

Figures in this Article

Introduction

"Prevention of Complications After Treatment of Femoral Shaft and Distal Femoral Fractures," by Robert F. Ostrum, MD, Jeffrey O. Anglen, MD, Michael T. Archdeacon, MD, MSE, Lisa K. Cannada, MD, and Dolfi Herscovici, DO

Intramedullary Fixation of Proximal Tibial Fractures

Fractures in the proximal one-third of the tibia are prone to malalignment, with the prevalence of that complication reported to be as high as 84%^2-4. The most common type of malalignment is apex-anterior and valgus angulation^2-6. Occasionally, a proximal tibial fracture is part of a segmental tibial fracture, which is not only a challenge to treat with nailing but also may have delayed healing. The anatomy of the proximal part of the tibia must be understood because it presents potential problems with fixation. First, the tibial metaphysis is wide, and insertion of the nail alone cannot effect reduction; thus, the metaphyseal portion of the tibia must be aligned with the shaft of the tibia by another method⁷. The forces of the patellar tendon contribute to the flexion deformity^3,4,6,7. As the knee is flexed for standard intramedullary nailing, a proximal tibial fracture becomes angulated as a result of the cephalad pull of the patellar tendon⁶. Methods to minimize this are described in this paper. Because the medial cortex of the proximal part of the tibia slopes from proximal to distal, if the starting point for the intramedullary nail is too medial, the nail insertion will produce a coronal plane deformity^4-6,8. When there is comminution of the posterior cortex, the nail may not be contained within the proximal fragment, leading to apex-anterior angulation⁴. Finally, insertion of a nail can be difficult because it requires hyperflexion of the knee, which can be problematic with a fracture in the proximal tibial metaphysis. As noted above, the intramedullary nail cannot be used to reduce a fracture in the proximal tibial metaphysis. The fracture must be reduced by manipulation, and the reduction must then be maintained while the tibia is reamed and until interlocking is completed. With proper technique, intramedullary nailing of proximal tibial fractures can lead to good results^4,5,7.

The geometry of tibial nails must be considered when one is planning their use. Tibial nails have a proximal posterior bend (Fig. 1), of up to 14° in some of them. The position of the bend in the nail also varies. Henley et al. showed that the more distal the bend of the nail, the greater the chance for proximal fracture malalignment². A tibial nail that is to be used for fixation of a fracture in the proximal metaphysis should have as proximal a bend as possible, and attention should be paid to the degree of curvature of the bend. It is also important to consider what locking options are available. Biomechanical studies have demonstrated that the construct stability of an oblique screw locking configuration is greater than that of a transverse locking configuration^9-11.

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Fig. 1: The proximal curvature of tibial nails can vary substantially.

There are several tricks for preventing malalignment when a nail is used to treat a proximal tibial fracture. The starting point for the nail is critical. To minimize problems with apex-anterior and valgus angulations, the starting point should be as proximal as possible and the guidewire should be advanced parallel to the anterior cortex (Fig. 2). If the leg is externally rotated, the starting point may be more medial than desired despite fluoroscopy¹². The optimum starting point is the medial aspect of the lateral tibial eminence, as this will place the nail in line with the medullary canal (Fig. 3). With most tibial shaft fractures, the starting point may be found with the use of a threaded guide pin or an awl, but for these difficult proximal fractures, it is better to use a threaded guide pin to provide a more precise starting point. In addition, in an article describing the use of a semiextended knee position, Tornetta and Collins reported two fractures that required augmentation because it was thought that the awl created too large a defect in the tibia⁶.

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Fig. 2: Lateral fluoroscopic view of the optimum starting point for proximal tibial nailing. Note that the guidewire is parallel to the anterior cortex.

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Fig. 3: Anteroposterior fluoroscopic view of the optimum starting point for proximal tibial nailing.

Under fluoroscopy, a femoral distracter can be used to facilitate reduction and stabilization of a proximal tibial fracture. The Schanz pins should be placed proximally and distally in the medial aspect of the tibia, parallel to the articular surface. Also, the proximal pins can be placed in the posterior aspect of the proximal part of the tibia to mimic a blocking screw⁷. External fixation can be used, in the same manner, as an alternative to the femoral distracter.

Nork et al. reviewed the cases of thirty-five patients with a total of thirty-seven fractures involving the proximal quarter of the tibia treated with intramedullary nailing⁷. They checked the behavior of the proximal fragment prior to nail insertion and discovered that, if the reduction was lost with knee flexion, it was important to use certain techniques to keep the fracture reduced⁷. They suggested use of a starting point for the nail that is parallel to the anterior cortex of the tibia and in line with the lateral intercondylar eminence, use of a medial femoral distractor, and/or augmentation of the fixation with a short plate. If a short plate is used to augment the fixation (discussed below), it can be left in place or removed at the discretion of the surgeon.

Instead of positioning the knee in flexion, Tornetta and Collins used a semiextended knee position for nail insertion⁶. They performed a medial parapatellar arthrotomy and subluxated the patella laterally. This minimized apex-anterior angulation and placed less tension on the soft tissues. With lateral subluxation of the patella, they could use the trochlear groove as a conduit for nail placement. In this technique, the knee was not flexed more than 10° to 15°. The disadvantage of the method is that it requires a formal arthrotomy.

Another option for preventing malalignment is to use a unicortical plate. One of us (M.T.A.) and Wyrick described "reduction plating" for provisional fixation of multiple long-bone fractures¹³. Benirschke et al. advocated this technique for the prevention of common deformities that occur with nail fixation of proximal tibial fractures¹⁴. One should plan ahead so that the plate is placed in the optimal position to assist with the reduction and not interfere with guidewire placement and reaming. A one-third tubular conventional or locking plate or a low-contact dynamic compression plate may be used with multiple unicortical screws 10 to 14 mm in length and with at least two screws in both the proximal and the distal segment. The plate can be placed subcutaneously. The use of a locking plate and screws adds more cost to the procedure, but the unicortical fixation provided by locking screws is stronger than that offered by standard unicortical screws. The reduction plate maintains the alignment of the fracture during the tibial nailing. If the surgeon chooses to remove the plate, he or she should not do so until after the proximal and distal locking screws of the nail have been placed.

The use of blocking screws with intramedullary nail fixation has been described as having good results in the treatment of fractures of the proximal third of the tibia^4,9. In addition to minimizing malalignment associated with the nailing of proximal tibial shaft fractures, blocking screws increase the stability of the construct by 25%, as demonstrated by Krettek et al.⁹. This is an important consideration when increased biomechanical strength is desired. Blocking screws are placed where the surgeon does not want the nail to go. The screw is placed lateral to the central axis to control valgus angulation. The nail then passes medial to the screw, and, as it passes across the fracture site, valgus angulation is avoided. A blocking screw is placed posterior to the central axis, with the nail passing anterior to it, to prevent apex-anterior angulation (Fig. 4). Ricci et al. used this technique to treat ten acute fractures and two malaligned nonunions⁴. Although the sample size was small, all patients had <5° of deformity postoperatively.

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Fig. 4: A blocking screw has been placed to minimize apex-anterior angulation.

There are alternatives for treatment of these fractures. Plate fixation is an attractive option for surgeons who are uncomfortable with intramedullary nailing. However, the patient must have a good soft-tissue envelope or the risk of a complication is excessive¹⁵. External fixation is another alternative with which to treat proximal tibial shaft fractures¹⁶. However, this procedure may require augmentation with bone graft to promote healing and should be reserved for fractures associated with so much soft-tissue injury that internal fixation is contraindicated.

The key to successful nailing of a proximal tibial fracture is to understand the fracture and its deforming forces and to maintain the reduction during the guidewire placement, subsequent reaming, nail placement, and locking of the nail. Careful attention to detail and respect for the unique difficulties presented by this fracture will result in acceptable reduction, stable fixation, and a high rate of healing.

Infections

Infection is a dreaded complication after any fracture but especially after tibial fractures, as the treatment of an infection in the tibia is a particular challenge. The infection rate following closed tibial shaft fractures is approximately 1%⁸. Open fractures are associated with higher infection rates: 5% for Gustilo and Anderson Type I, 10% for Type II, and >15% for Type III⁸. The soft-tissue injury is a key factor affecting the risk of infection, and the appropriate treatment of that injury has a strong influence on the outcome.

The key to preventing infection following an open tibial fracture begins with the initial débridement. Meticulous techniques should be used to débride the fracture from the outside skin portion through to the deep osseous portion. All nonviable tissue, both osseous and soft tissue, should be removed. If there is any doubt regarding the viability of the tissue or bone, it should be taken out. The exception is articular cartilage and the subchondral bone, which should be preserved if at all possible. The extent of the soft-tissue injury does not completely manifest itself initially, and there may be necrotic tissue that appears viable at the initial débridement; therefore, multiple débridements should be done.

When an external fixator is initially used, it is best to convert it to a definitive internal fixation device within the first seven days, as increased infection rates have been reported in association with delayed conversion^17,18.

Early soft-tissue coverage of Type-IIIA fractures helps to prevent infection, and the timing of the coverage is crucial for the success of treatment. Fischer et al. evaluated forty-three patients with a Type-IIIB tibial fracture to determine the effect of treatment of the soft-tissue injury on the rate of complications¹⁹. Infection developed in two of the eleven patients treated with early muscle-flap coverage, in ten of the nineteen treated with open wound care, and in nine of the thirteen treated with delayed flap coverage. Fischer et al. concluded that early flap coverage is important to reduce the infection rate. This finding is consistent with a previous report¹⁹ that the highest rate of complications occurs when flap coverage is done more than two weeks after the injury. It is believed that the wound is only contaminated with bacteria initially but becomes colonized during the first two weeks and this is what leads to the increased risk of infection associated with delayed closure¹⁹. A flap placed early provides a healthy environment, promotes healing, and increases blood supply, leading to re-epithelialization. All of those factors decrease wound colonization and the risk of contamination of deeper tissues.

Infections may develop in the acute period, which is defined as less than four weeks after the injury⁸. They also can occur several months to years after the injury. It is not necessarily easy to recognize these late infections, and one must be aware of this possibility. A type or mechanism of initial injury that predisposes a patient to infection should make one more vigilant about detecting this complication. Was there a major crush component? Was there soft-tissue devitalization? Was an open fracture sustained in a contaminated environment (involving, for example, soil, chemicals, or murky lake water)? These factors may contribute to indolent or delayed infection.

Comorbidities contribute to the risk of an infection. The nutritional status is important, and often patients who have sustained trauma are protein-depleted. A patient may be immunocompromised, have diabetes, use tobacco, or abuse drugs or alcohol. When possible, these host comorbidities should be treated while the fracture is being treated. The patient's nutritional status is evaluated by measuring the blood glucose level, serum prealbumin level, total protein level, and lymphocyte count. When a patient has diabetes, the blood sugar level should be carefully controlled. Smokers are more prone to infection, and it is well known that their fracture-healing time is increased by up to 40%^20-22. Patients with a systemic disease such as rheumatoid arthritis may be taking medications that interfere with healing and may be more prone to infection²³. Patients with vascular insufficiency may have important circulatory issues. A heightened index of suspicion for infection should be maintained for patients with any of these comorbidities.

Obvious signs and symptoms of infection include increasing pain, swelling, erythema, fever, chills, and purulent drainage (Figs. 5-A and 5-B), but prolonged or increasing pain may be the only clue that the patient has an infection. The periosteal reaction usually seen with hematogenous osteomyelitis may not be present, and bone scans can be inaccurate; false-negative scans are not uncommon. If infection is suspected, determination of a complete blood-cell count with a differential, the erythrocyte sedimentation rate, and the C-reactive protein level may help one make the diagnosis. The erythrocyte sedimentation rate may be elevated as a result of the injury and surgery, but it should decrease with time. C-reactive protein is an acute-phase reactant, and it should return to normal after the injury more quickly than the erythrocyte sedimentation rate. If it remains elevated, infection should be considered. Furthermore, the C-reactive protein level provides a means of determining the effectiveness of treatment of an infected wound.

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Fig. 5-A: Figs. 5-A and 5-B Photographs of a patient with purulent wound drainage. Fig. 5-A Before débridement.

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Fig. 5-B: After débridement. Note the exposed intramedullary nail.

Once an infection has been identified, treatment should be definitive. The most important part of management is débridement²⁴ to remove all nonviable bone and soft tissue. Aggressive débridement should be repeated until the wound is clean and has an acceptable soft-tissue envelope. Soft-tissue and bone specimens should be obtained for culture, and the appropriate systemic antibiotic therapy should be instituted^24,25.

If the débrided wound cannot be closed, a vacuum-assisted closure device may be used until there is adequate granulation tissue to support appropriate coverage. The ultimate goal is soft-tissue coverage but not until the tissue bed is acceptable.

Direct application of antibiotics seems to be beneficial, and a variety of options are available to deliver a high concentration of local antibiotics²⁶. Polymethylmethacrylate beads mixed with antibiotics can be used. These beads provide an advantage due to their surface area and the local delivery of the antibiotics. The disadvantage of using polymethylmethacrylate beads is that the maximum antibiotic concentration is delivered within the first two weeks and a second operative procedure is required to remove the beads. Calcium sulfate pellets are a commercially available alternative. These can be mixed with antibiotics and do not require removal. Unfortunately, the pellets can stimulate local inflammation with drainage that may be mistaken for an infection. Systemic antibiotic administration is recommended, and six weeks of culture-specific intravenous antibiotics is usually sufficient. Monitoring the erythrocyte sedimentation rate and C-reactive protein level assists in the determination of when the infection is controlled. It is also important to routinely monitor renal and hepatic function when drugs that are cleared through those major organ systems are used. A controversial topic is when the implant should be removed. When the infection develops early, before any healing occurs, the patient should be treated with aggressive débridement, wound closure, and suppressive antibiotics without removal of the hardware. When this is done, the healing rate can approach 90%⁸. When the infection is diagnosed more than four weeks after the injury, the hardware may need to be removed to eradicate the infection. If the fixation is unstable, the implant should be removed, the infected area should be débrided, and appropriate antibiotics should be administered to treat the infection. An external fixation device may be needed to control the unstable fracture. If necessary, internal fixation may be performed later, but only after wound specimens are culture-negative and the patient is receiving an appropriate systemic antibiotic. If the fixation is stable and the soft tissues are healthy but the fracture is not healed, it may be possible to retain the hardware, perform a thorough débridement, and use local and systemic antibiotics. If the infection returns or if signs of deep infection persist, the implant should be removed.

Aseptic Nonunions

Nonunions are frustrating for both the patient and the surgeon. Aseptic nonunion occurs after approximately 3% of closed tibial shaft fractures⁸. The nonunion rate after open fractures is 15% or greater depending on the degree of the soft-tissue injury. A patient with a nonunion is subjected to multiple surgical procedures and additional hospitalizations and has an increased duration of disability. An amputation may eventually be needed. Being aware of which fractures have an increased potential for healing problems is valuable, as this allows earlier intervention, which reduces the time to union. The orthopaedic community has not agreed on the length of time required for a tibial fracture to heal, but the U.S. Food and Drug Administration (FDA) has defined "nonunion" as a fracture that occurred a minimum of nine months previously and has no radiographic signs of progression toward healing for three consecutive months^27,28.

Nonunions are classified, on the basis of the radiographic appearance, as either hypertrophic or atrophic. Hypertrophic nonunions have abundant callus surrounding the bone but a persistent radiolucent line at the fracture site. They are considered to have an adequate biological environment but to lack sufficient mechanical stability. In contrast, atrophic nonunions are seen to have little or no callus on radiographs and are considered to be due to an inadequate biological environment.

Numerous factors contribute to an aseptic nonunion. Host factors that increase the risk of nonunion are similar to those that predispose a patient to the development of an infection. Patients with diabetes mellitus have longer fracture-healing times²⁹. Smokers have an increased rate of nonunion and more soft-tissue healing problems than do nonsmokers^20-22. Several medications may interfere with fracture-healing. These include nonsteroidal anti-inflammatory drugs and bisphosphonates when taken in the early postoperative period^23,30.

Nutrition is a factor that also needs to be considered when a patient has a nonhealing fracture. Even an overweight patient may be malnourished. Inadequate nutritional status is defined by an albumin level of <34 g/L and a lymphocyte count of <1500/mm³ (<1.5 × 10⁹/L)^31,32.

The fracture pattern itself is an important factor. A transverse fracture may not be as simple as it seems. Bhandari et al. noted that a transverse fracture pattern was associated with an increased need for a reoperation to promote healing³³. Open fractures are more prone to nonunion than are closed fractures, with the higher nonunion rate probably due to periosteal stripping and disruption of the soft-tissue envelope³⁴. The condition of the soft tissues is the most important factor contributing to nonunions, and a closed injury may also be associated with extensive soft-tissue damage and not heal^35,36. To assess the extent of the injury, one should palpate the soft-tissue envelope and note whether degloving or other soft-tissue disruption has occurred.

The initial management of the fracture can influence healing. Concerns that reaming of the sites of open fractures would increase nonunion rates have been alleviated, and multiple studies have since demonstrated that reaming is actually beneficial when done judiciously and indeed may lead to higher union rates^26,37-43. With intramedullary reaming, a large nail can be used and stability can be achieved. Static interlocking of tibial nails proximally and distally is recommended^44,45. Before locking, one should ensure that there is bone-on-bone contact because, without it, a reoperation may be necessary to achieve osseous union³³.

Once a nonunion is diagnosed there are several operative and nonoperative treatment options. One nonoperative option is weight-bearing in a cast^46,47. With this method, there is still some protection of the fracture site and the load-bearing may stimulate healing. Low-intensity pulsed ultrasound is another nonoperative option, although its role in the treatment of nonunion is controversial³¹. Diagnostic ultrasound can help determine which patients are candidates for surgical intervention, and it has been used to document whether there is callus formation in the early healing period following tibial fractures that are at a high risk for nonunion⁴⁸. Electrical stimulation is another nonoperative treatment option. Many companies sell electrical stimulators; currently, six external bone-growth stimulators are being sold, and all are FDA-approved for the treatment of nonunions. Bassett described a noninvasive system using pulsed electromagnetic fields⁴⁹. This is effective if the nonunion gap is <1 cm, with union rates ranging from 82% to 87%⁴⁹. The value of electrical stimulation in the management of a patient with a nonunion remains controversial, in part because of a lack of studies with a high level of evidence.

There are a variety of operative options for an aseptic nonunion. If the patient has an intramedullary rod with proximal and distal screws, one set of screws can be removed to allow compression across the fracture with weight-bearing. This is called "dynamization" and can often be done as an outpatient procedure with the use of local anesthesia. However, the value of this procedure has not been well documented in studies with a high level of evidence. Court-Brown et al. reported that dynamization had little effect on the speed of union⁵⁰. Wu and Shih observed a 54% rate of union of long-bone fractures after dynamization⁵¹. Complications that may occur with removal of a locking screw are loss of fixation and migration of the nail; therefore, screw removal should be done cautiously, especially in the setting of a comminuted fracture or when the nail is very close to either end of the tibia.

Removing the initially placed intramedullary nail and reaming the canal to insert a larger nail is called exchange nailing. This has been shown to be beneficial in the treatment of aseptic nonunions^{28,31,45,46,52-55}. The objective is to ream the canal and place a nail that is at least 1 mm larger than the existing nail. We recommend that, when an exchange nailing is performed for what is thought to be an aseptic nonunion, deep reaming specimens be sent for culture. These cultures may be positive despite laboratory indices that did not demonstrate infection, and then antibiotics can be given.

Templeman et al. reported that twenty-five of twenty-seven tibial fractures that had been initially treated with unreamed nailing and subsequently underwent an exchange nailing between three and five months after the injury united after the exchange nailing⁵⁴. The two fractures that did not heal were associated with bone loss and required an open bone-grafting procedure to unite. The authors concluded that the procedure is safe for closed and minor open fractures but cautioned that it was associated with an increased infection rate when used for Type-IIIB fractures.

Court-Brown et al. reviewed the results in thirty-three patients with an aseptic nonunion treated with exchange nailing⁵². All closed and Type-I, II, and IIIA open fractures united, but the exchange nailing failed and open bone-grafting was required for Type-IIIB fractures with bone loss. The authors reported that the most common complication was wound infection, which developed more often than it did after primary nailing.

Muller and Thomas postulated two reasons why exchange nailing stimulates bone union⁴⁵. The first is the increased stability provided for a hypertrophic nonunion. The second reason is that the reaming products promote healing because of their osteoinductive potential. Others have demonstrated that reaming of the intramedullary canal is associated with new bone production, and this accounts for the increased new bone after exchange nailing^52,54. Overall, exchange nailing is an excellent method for the treatment of aseptic nonunions; however, the increased infection rate associated with Type-IIIB fractures is a concern.

Plate fixation is another option for the operative treatment of an aseptic tibial nonunion following the initial treatment of a fracture with an intramedullary nail³¹. Compression plate fixation is best reserved for treatment in conjunction with bone-grafting^56,57. Plates are load-bearing devices, and therefore protected weight-bearing is required until healing has occurred. In addition, the infection rate associated with plate fixation is higher than that associated with other methods. If the fracture is malaligned, a plate can be used to correct the alignment^31,46,58.

Another operative technique for aseptic nonunions is external fixation, such as the Ilizarov method. External fixation, either uniplanar or multiplanar, is especially useful for the management of nonunions associated with extensive soft-tissue damage, and deformity can be corrected with the Ilizarov technique. The success of external fixation depends on the patient's cooperation, and it is technically demanding. Pin-track complications are quite common, and additional operations may be required to promote fracture-healing.

Bone-grafting may be necessary in the treatment of some aseptic nonunions and should be considered primarily for atrophic nonunions^56,57. The nonunion must be stable; the placement of bone graft alone is insufficient treatment when the nonunion remains unstable. There are several options for bone-grafting of tibial defects. We prefer a posterolateral approach, which is done with the patient in a lateral or prone position. The bone graft is harvested from the iliac crest only after the recipient site has been prepared to receive it. The possibility of infection at the nonunion site should be excluded, a thorough débridement should be done, and internal fixation should be accomplished. Once the bone graft has been harvested, it should be packed immediately into the nonunion site.

There are also several commercially available adjuncts, including two types of bone morphogenetic proteins (BMPs), to stimulate bone-healing. Recombinant human bone morphogenetic protein-7 (rhBMP-7) was shown to promote union in a prospective study of 122 patients with a total of 124 tibial nonunions⁵⁹. Nine months after surgery, 81% of the patients treated with rhBMP-7 and 85% of those treated with autogenous bone graft were judged to have a healed fracture on the basis of clinical findings, whereas 75% of the rhBMP-7 group and 85% of the autogenous-bone-graft group were judged to have healing on the basis of the radiographic appearance. These results suggest that BMP is just as effective as autogenous bone graft for the treatment of tibial nonunions, and, on the basis of these results, the FDA approved the use of BMP-7 under a humanitarian device exemption.

RhBMP-2 was evaluated in two recent studies with Level-I evidence. In a prospective randomized study, 299 patients with an open tibial fracture were treated with an intramedullary nail and rhBMP-2⁵⁹. The use of rhBMP-2 decreased the risk of secondary intervention by 41% (p = 0.001) and reduced the nonunion rate by 29% (p = 0.0075). Overall, there was a 44% reduction in the infection rate as well. The FDA has approved rhBMP-2 for use in open tibial fractures treated with intramedullary fixation within the first fourteen days after the injury. The use of rhBMP-2 in the acute stages may decrease the rates of nonunion and infection. RhBMP-2 was evaluated in another prospective study, of acute open or closed tibial fractures with associated bone loss that required a planned staged reconstruction⁶⁰. The fracture defects ranged in size from 1 to 7 cm, with 50% to 100% circumferential bone loss. Of the thirty patients in the study, fifteen received rhBMP-2 and allografts and fifteen received autogenous bone grafts. Two patients in the rhBMP-2 group and four patients in the autogenous-bone-graft group required a secondary intervention. There was a comparable rate of healing in the two groups and fewer problems related to the donor site in the rhBMP-2 group. The authors concluded that allograft with rhBMP-2 was an alternative to autogenous bone graft for the treatment of tibial fractures with a bone defect.

Overview

In conclusion, it can be a challenge to obtain optimum results following a tibial shaft fracture. The surgeon should evaluate the factors that are controllable and plan properly. This will improve the overall results.

References

Russell TA. Fractures of the tibial diaphysis. In: Levine AM, editor. Orthopaedic knowledge update: trauma. Vol. 1. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1996. p 171-9. 1996

Henley MB, Meier M, Tencer AF. Influences of some design parameters on the biomechanics of the unreamed tibial intramedullary nail. J Orthop Trauma.1993;7:311-9.7311 1993 [CrossRef]

Lang GJ, Cohen BE, Bosse MJ, Kellam JF. Proximal third tibial shaft fractures. Should they be nailed? Clin Orthop Relat Res.1995;315:64-74.31564 1995

Ricci WM, O'Boyle M, Borrelli J, Bellabarba C, Sanders R. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma.2001;15:264-70.15264 2001 [CrossRef]

Buehler KC, Green J, Woll TS, Duwelius PJ. A technique for intramedullary nailing of proximal third tibia fractures. J Orthop Trauma.1997;11:218-23.11218 1997 [CrossRef]

Tornetta P 3rd, Collins E. Semiextended position of intramedullary nailing of the proximal tibia. Clin Orthop Relat Res.1996;328:185-9.328185 1996 [CrossRef]

Nork SE, Barei DP, Schildhauer TA, Agel J, Holt SK, Schrick JL, Sangeorzan BJ. Intramedullary nailing of proximal quarter tibial fractures. J Orthop Trauma.2006;20:523-8.20523 2006 [CrossRef]

Shuler FD, Obremskey WT. Tibial shaft fractures. In: Stannard JP, Schmidt AH, Kregor PJ, editors. Surgical treatment of orthopaedic trauma. New York: Thieme; 2007. p 742-66. 2007

Krettek C, Miclau T, Schandelmaier P, Stephan C, Möhlmann U, Tscherne H. The mechanical effect of blocking screws ("Poller screws") in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter intramedullary nails. J Orthop Trauma.1999;13:550-3.13550 1999 [CrossRef]

Laflamme GY, Heimlich D, Stephen D, Kreder HJ, Whyne CM. Proximal tibial fracture stability with intramedullary nail fixation using oblique interlocking screws. J Orthop Trauma.2003;17:496-502.17496 2003 [CrossRef]

Roth SE, Kreder H, Stephen D, Whyne CM. Biomechanical stability of intramedullary nailed high proximal third tibial fractures with cement augmented proximal screws. J Orthop Trauma.2005;19:457-61.19457 2005 [CrossRef]

Walker R, McKee MD, Waddell JP, Schemitsch EH. Ideal tibial intramedullary nail insertion point varies with tibial rotation. Presented as a poster exhibit at the 2006 Annual Meeting of the Orthopaedic Trauma Association; 2006 Oct 5-7; Phoenix, AZ. Poster no. 74. 2006

Archdeacon MT, Wyrick JD. Reduction plating for provisional fracture fixation. J Orthop Trauma.2006;20:206-11.20206 2006 [CrossRef]

Benirschke SK, Henley MB, Ott JW. Proximal one third tibial fracture solutions. Orthop Trans.1995;18:1055-6.181055 1995

Cole PA, Zlowodzki M, Kregor PJ. Treatment of proximal tibia fractures using the less invasive stabilization system: surgical experience and early clinical results in 77 fractures. J Orthop Trauma.2004;18:528-35.18528 2004 [CrossRef]

Lundy DW, Albert MJ, Hutton WC. Biomechanical comparison of hybrid external fixators. J Orthop Trauma.1998;12:496-503.12496 1998 [CrossRef]

Törnqvist H. Tibia nonunions treated by interlocked nailing: increased risk of infection after previous external fixation. J Orthop Trauma.1990;4:109-14.4109 1990 [CrossRef]

Maurer DJ, Merkow RL, Gustilo RB. Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation. J Bone Joint Surg Am.1989;71:835-8.71835 1989

Fischer MD, Gustilo RB, Varecka TF. The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. J Bone Joint Surg Am.1991;73:1316-22.731316 1991

Adams CI, Keating JF, Court-Brown CM. Cigarette smoking and open tibial fractures. Injury.2001;32:61-5.3261 2001 [CrossRef]

Castillo RC, Bosse MJ, MacKenzie EJ, Patterson BM; LEAP Study Group. Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures. J Orthop Trauma.2005;19:151-7.19151 2005 [CrossRef]

Schmitz MA, Finnegan M, Natarajan R, Champine J. Effect of smoking on tibial shaft fracture healing. Clin Orthop Relat Res.1999;365:184-200.365184 1999 [CrossRef]

Gerstenfeld LC, Thiede M, Seibert K, Mielke C, Phippard D, Svagr B, Cullinane D, Einhorn TA. Differential inhibition of fracture healing by non-selective and cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs. J Orthop Res.2003;21:670-5.21670 2003 [CrossRef]

Cierny G 3rd, Mader JT. Approach to adult osteomyelitis. Orthop Rev.1987;16:259-70.16259 1987

Moehring HD, Gravel C, Chapman MW, Olson SA. Comparison of antibiotic beads and intravenous antibiotics in open fractures. Clin Orthop Relat Res.2000;372:254-61.372254 2000 [CrossRef]

Holtom PD, Patzakis MJ. Newer methods of antimicrobial delivery for bone and joint infections. Instr Course Lect.2003;52:745-9.52745 2003

Bhandari M, Guyatt GH, Swiontkowski MF, Tornetta P 3rd, Sprague S, Schemitsch EH. A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthop Trauma.2002;16:562-6.16562 2002 [CrossRef]

LaVelle DG. Delayed union and nonunion of fractures. In: Canale ST, editor. Campbell's operative orthopaedics. 9th ed, vol. 3. St. Louis: Mosby; 1998. p 2579-629. 1998

Loder RT. The influence of diabetes mellitus on the healing of closed fractures. Clin Orthop Relat Res.1988;232:210-6.232210 1988

Giannoudis PV, MacDonald DA, Matthews SJ, Smith RM, Furlong AJ, De Boer P. Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg Br.2000;82:655-8.82655 2000 [CrossRef]

Phieffer LS, Goulet JA. Delayed unions of the tibia. J Bone Joint Surg Am.2006;88:206-16.88206 2006 [CrossRef]

Jensen JE, Jensen TG, Smith TK, Johnston DA, Dudrick SJ. Nutrition in orthopaedic surgery. J Bone Joint Surg Am.1982;64:1263-72.641263 1982

Bhandari M, Tornetta P 3rd, Sprague S, Najibi S, Petrisor B, Griffith L, Guyatt GH. Predictors of reoperation following operative management of fractures of the tibial shaft. J Orthop Trauma.2003;17:353-61.17353 2003 [CrossRef]

Karladani AH, Granhed H, Kärrholm J, Styf J. The influence of fracture etiology and type on fracture healing: a review of 104 consecutive tibial shaft fractures. Arch Orthop Trauma Surg.2001;121:325-8.121325 2001 [CrossRef]

Henley MB, Chapman JR, Agel J, Harvey EJ, Whorton AM, Swiontkowski MF. Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective comparison of unreamed interlocking intramedullary nails and half-pin external fixators. J Orthop Trauma.1998;12:1-7.121 1998 [CrossRef]

Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg Br.1995;77:417-21.77417 1995

Bhandari M, Guyatt GH, Tong D, Adili A, Shaughnessy SG. Reamed versus nonreamed intramedullary nailing of lower extremity long bone fractures: a systematic overview and meta-analysis. J Orthop Trauma.2000;14:2-9.142 2000 [CrossRef]

Schandelmaier P, Krettek C, Rudolf J, Tscherne H. Outcome of tibial shaft fractures with severe soft tissue injury treated by unreamed nailing versus external fixation. J Trauma.1995;39:707-11.39707 1995 [CrossRef]

Shannon FJ, Mullett H, O'Rourke K. Unreamed intramedullary nail versus external fixation in grade III open tibial fractures. J Trauma.2002;52:650-4.52650 2002 [CrossRef]

Tornetta P 3rd, Bergman M, Watnik N, Berkowitz G, Steuer J. Treatment of grade-IIIb open tibial fractures. A prospective randomised comparison of external fixation and non-reamed locked nailing. J Bone Joint Surg Br.1994;76:13-9.7613 1994

Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF. A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma.2000;14:187-93.14187 2000 [CrossRef]

Court-Brown CM, Will E, Christie J, McQueen MM. Reamed or unreamed nailing for closed tibial fractures. A prospective study in Tscherne C1 fractures. J Bone Joint Surg Br.1996;78:580-3.78580 1996

Schemitsch EH, Kowalski MJ, Swiontkowski MF, Harrington RM. Comparison of the effect of reamed and unreamed locked intramedullary nailing on blood flow in the callus and strength of union following fracture of the sheep tibia. J Orthop Res.1995;13:382-9.13382 1995 [CrossRef]

Templeman D, Larson C, Varecka T, Kyle RF. Decision making errors in the use of interlocking tibial nails. Clin Orthop Relat Res.1997;339:65-70.33965 1997 [CrossRef]

Muller ME, Thomas RJ. Treatment of non-union in fractures of long bones. Clin Orthop Relat Res.1979;138:141-53.138141 1979

Wiss DA, Stetson WB. Tibial nonunion: treatment alternatives. J Am Acad Orthop Surg.1996;4:249-57.4249 1996

Sarmiento A, Burkhalter WE, Latta LL. Functional bracing in the treatment of delayed union and nonunion of the tibia. Int Orthop.2003;27:26-9.2726 2003

Moed BR, Subramanian S, van Holsbeeck M, Watson JT, Cramer KE, Karges DE, Craig JG, Bouffard JA. Ultrasound for the early diagnosis of tibial fracture healing after static interlocked nailing without reaming: clinical results. J Orthop Trauma.1998;12:206-13.12206 1998 [CrossRef]

Bassett CA. The development and application of pulsed electromagnetic fields (PEMFs) for ununited fractures and arthrodeses. Orthop Clin North Am.1984;15:61-87.1561 1984

Court-Brown CM, Christie J, McQueen MM. Closed intramedullary tibial nailing. Its use in closed and type I open fractures. J Bone Joint Surg Br.1990;72:605-11.72605 1990

Wu CC, Shih CH. Effect of dynamization of a static interlocking nail on fracture healing. Can J Surg.1993;36:302-6.36302 1993

Court-Brown CM, Keating JF, Christie J, McQueen MM. Exchange intramedullary nailing. Its use in aseptic tibial nonunion. J Bone Joint Surg Br.1995;77:407-11.77407 1995

Sledge SL, Johnson KD, Henley MB, Watson JT. Intramedullary nailing with reaming to treat non-union of the tibia. J Bone Joint Surg Am.1989;71:1004-19.711004 1989

Templeman D, Thomas M, Varecka T, Kyle R. Exchange reamed intramedullary nailing for delayed union and nonunion of the tibia. Clin Orthop Relat Res.1995;315:169-75.315169 1995

Mayo KA, Benirschke SK. Treatment of tibial malunions and nonunions with reamed intramedullary nails. Orthop Clin North Am.1990;21:715-24.21715 1990

Hanson LW, Eppright RH. Posterior bone-grafting of the tibia for non-union: a review of twenty-four cases. J Bone Joint Surg Am.1966;48:27-43.4827 1966

Simpson JM, Ebraheim NA, An HS, Jackson WT. Posterolateral bone graft of the tibia. Clin Orthop Relat Res.1990;251:200-6.251200 1990

Wiss DA, Johnson DL, Miao M. Compression plating for non-union after failed external fixation of open tibial fractures. J Bone Joint Surg Am.1992;74:1279-85.741279 1992

Govender S, Csimma C, Genant HK, Valentin-Opran A, Amit Y, Arbel R, Aro H, Atar D, Bishay M, Börner MG, Chiron P, Choong P, Cinats J, Courtenay B, Feibel R, Geulette B, Gravel C, Haas N, Raschke M, Hammacher E, van der Velde D, Hardy P, Holt M, Josten C, Ketterl RL, Lindeque B, Lob G, Mathevon H, McCoy G, Marsh D, Miller R, Munting E, Oevre S, Nordsletten L, Patel A, Pohl A, Rennie W, Reynders P, Rommens PM, Rondia J, Rossouw WC, Daneel PJ, Ruff S, Rüter A, Santavirta S, Schildhauer TA, Gekle C, Schnettler R, Segal D, Seiler H, Snowdowne RB, Stapert J, Taglang G, Verdonk R, Vogels L, Weckbach A, Wentzensen A, Wisniewski T; BMP-2 Evaluation in Surgery for Tibial Trauma (BESTT) Study Group. Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients. J Bone Joint Surg Am.2002;84:2123-34.842123 2002

Jones AL, Bucholz RW, Bosse MJ, Mirza SK, Lyon TR, Webb LX, Pollak AN, Golden JD, Valentin-Opran A; BMP-2 Evaluation in Surgery for Tibial Trauma-Allograft (BESTT-ALL) Study Group. Recombinant human BMP-2 and allograft compared with autogenous bone graft for reconstruction of diaphyseal tibial fractures with cortical defects. A randomized, controlled trial. J Bone Joint Surg Am.2006;88:1431-41.881431 2006 [CrossRef]

Topics

fracture ; bone nails ; tibia ; tibial fractures ; infection

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Lisa K. Cannada, Jeffrey O. Anglen, Michael T. Archdeacon, Dolfi HerscoviciJr., Robert F. Ostrum; Avoiding Complications in the Care of Fractures of the Tibia. The Journal of Bone & Joint Surgery. 2008 Aug;90(8):1760-1768.

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