Intramedullary nailing after external fixation of the tibia.
Intramedullary nailing after external fixation of fractures of the tibia has high complication rates including nonunion and infection. The authors review the literature regarding this technique and refine the indications for secondary IM nailing. The report distinguishes between sequential secondary nailing and reconstructive secondary nailing. Sequential secondary nailing, as defined, is done by protocol and is planned from the onset of treatment. The technique includes only a short period in the external fixator, a planned interval between removal of the frame and placement of the IM nail, and specific exclusion criteria. This technique essentially uses the external fixator as a temporary traction device while the soft tissue envelope is reconstructed. Reconstructive procedures, as defined, are not done by protocol and not planned from the onset of treatment. Patients are usually in the external fixator for extended periods of time. The indications are variable and include delayed union, nonunion, malunion, and infected nonunion. The authors conclude that when done by protocol sequential IM nailing is safe and effective. Reconstructive IM nailing, however, has strict contraindications that include: a history of or an active infection of the pin tract, wound, or bone; the presence of an open wound or pin tract; and the presence of a ring or halo sequestrum. Yet reconstructive secondary procedures can be effective in healthy individuals if the soft tissue envelope is completely reestablished, if antibiotics are administered preoperatively, and the nail is placed without reaming.
University Hospital of Brooklyn, Department of Orthopedics, NY 11203, USA.
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Tornetta
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DeMarco
D000328:Adult; D002985:Clinical Protocols; D016267:External Fixators; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects / Q000379:methods*; D017102:Fracture Healing; D005597:Fractures, Open / Q000601:surgery; D005599:Fractures, Ununited / Q000601:surgery; D006801:Humans; D008297:Male; D010019:Osteomyelitis / Q000209:etiology; D010347:Patient Care Planning; D017695:Soft Tissue Injuries / Q000601:surgery; D013978:Tibial Fractures / Q000601:surgery*