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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 83-89

Unreamed solid interlocking nail for the management of compound tibial diaphyseal fracture? A prospective study


1 Department of Orthopaedics, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Orthopaedics, UCMS and GTB Hospital, New Delhi, India

Date of Submission20-Apr-2020
Date of Decision04-Jun-2020
Date of Acceptance09-Jul-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Ashiwani Kumar Pankaj
Department of Orthopaedics, All India Institute of Medical Sciences, Patna - 801 507, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_13_20

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  Abstract 


Background: Compound tibial fractures have always been a challenge to the orthopedic fraternity. Goals of treating these fractures are preventing infection, restoring soft-tissue vitality, achieving union, and instituting early joint motion and rehabilitation. Aim: The aim was to evaluate the rate of union, infection rate, post-union deformity, and the functional outcome following unreamed solid interlocking nailing in compound tibial diphyseal fracture of Gustilo–Anderson Grade I to IIIB. Materials and Methods: Twenty patients presenting to the emergency orthopedic department with compound tibial fractures, between 2014 and 2016, were included in the study. This was a hospital-based, prospective study. The fractures were classified according to Gustilo–Anderson classification, and the final outcome was measured by Johner and Wruh's criteria with modification. Results: We had more cases of male patients than females (75% vs. 25%) in the age group of 20–60 years (average 37.10). Road traffic accident was the most common cause in our study (75%) followed by fall from height (25%). Gustilo and Anderson classification was used, and 10% were Grade I, 20% were Grade II, 65% were Grade IIIA, and 5% were Grade IIIB. The average time to union was 22.53 weeks and the average time to start full weight bearing was 11 weeks with a standard deviation of 1.38 weeks. Complications such as delayed union (10%), nonunion (5%), shortening (5%), superficial infection (10%), gait disturbance (5%), and angulation (10%) were found; 5% had more than 25° of restriction of ankle rom and 5% had more than 10° of restriction of knee rom. Final outcome was excellent results in 65%, good in 20%, fair in 10%, and poor in 5% of cases. Conclusion: The present study demonstrates that unreamed solid interlocking nailing is considered a good option for the management of compound tibial fractures (Grade I–IIIB) as it allows early weight bearing, early rehabilitation with high union rate, and low complication rate.

Keywords: Compound tibial fracture, open tibial fracture, unreamed solid nail


How to cite this article:
Pankaj AK, Goyal V K. Unreamed solid interlocking nail for the management of compound tibial diaphyseal fracture? A prospective study. J Orthop Dis Traumatol 2020;3:83-9

How to cite this URL:
Pankaj AK, Goyal V K. Unreamed solid interlocking nail for the management of compound tibial diaphyseal fracture? A prospective study. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Oct 21];3:83-9. Available from: https://www.jodt.org/text.asp?2020/3/2/83/294726




  Introduction Top


The tibial shaft is prone to open fractures more than any other long bone. Epidemiological studies have shown that open fractures comprise 23.5% of all tibial shaft fractures. The lack of muscular protection along the anteromedial aspect of the tibia and the poor blood supply predisposes open tibia fractures to 10–20 times higher risk of infection and 28% higher risk of nonunion than any other open fractures.[1] Early stabilization of open fractures provides many benefits to the injured patient. It protects the soft tissues around the zone of injury by preventing further damage from mobile fracture fragments. It also restores length, alignment, and rotation. This restoration of length also helps to decrease soft-tissue dead spaces and consequently decreases the rate of infection in open fractures. Early fixation allows improved access to soft tissues surrounding the injury and facilitates patient's early return to normal function.[1] The goals of treating these fractures are preventing infection, restoring soft-tissue vitality, achieving union, and instituting early joint motion and rehabilitation. Because of the high prevalence of complications associated with these fractures, the optimum method of treatment remains a subject of controversy. Every fracture is an individual problem, and decisions to treat it by internal fixation or conservatively should be best on a realistic assessment of the advantages and the hazards of each method in the circumstances of the particular case.[2] Among the various modalities of the treatment such as gentle manipulation and use of long leg cast with window cutout for wound management, functional cast bracing (Sarmiento), open reduction and internal fixation with plate and screws, intramedullary fixation (interlocking nail [ILN] with or without reaming), and the external fixators, the best treatment modality must be determined by a thoughtful analysis of morphology of fracture, amount of energy imparted to the extremity, the mechanical characteristics of the bone, the age and general condition of the patient, and most importantly the status of surrounding soft tissues.[3] Immobilization in plaster cast with window cutout for wound management has been used most commonly in the past, but it does not maintain the length of tibia and leaves the bone relatively inaccessible.[4] External fixators have many disadvantages such as restriction of joint motion, pin-site infection, high rates of mal-union and nonunion, and a requirement of a second surgery after removal of external fixators. In addition, external fixators could be cumbersome and are not always well tolerated by patient.[5] Plating requires soft-tissue stripping, which can lead to wound complications, infection, and metal fatigue failure. Thus, we turn our attention to intramedullary nailing.[6] The osteosynthesis of a compound tibial fracture with a ILN carries the advantage of high union rates, low infection and deformity rates, and good functional results. Complications of ILN include knee pain, possible injury to the anterior tibial artery, superficial peroneal nerve, and breaking of the screws. Until recently, all the intramedullary nailing involved reaming, but undoubtedly reaming provides wider and uniform medullary cavity to insert a bigger diameter nail which closely and snuggly fits into the medullary cavity, providing a stable fixation. But of late, the reports of hazardous consequences of reaming have come to light. Some of them such as fat embolism, destruction of endosteal blood supply,[7] and higher infection rate in case of open tibial fracture, to name a few, have caused a lot of postoperative morbidity and mortality. Studies have shown early revascularization, less bone grafting rate, less reduction to cortical circulation, and consequently less complications such as infection and compartment syndrome in unreamed ILN. The advantages of solid nail over cannulated nail are that the former is stronger and carries less chances of fat embolism and infection.[8] Unreamed solid ILNs have been employed successfully in the treatment of open tibial fractures and have been associated with low rates of postoperative infection. Unreamed nailing has the major advantage in case of open fractures because they cause less damage to the endosteal blood supply and allow more room for revascularization. Their disadvantage lies in the fact that they are less stable and hence frequently lead to delayed unions, nonunions, and malunions.[8]


  Materials and Methods Top


The study was conducted on patients who presented to the Department of Orthopaedics, Deendayal Upadhyay Hospital, Delhi, with compound tibial fractures between 2014 and 2016, after obtaining informed consent from the patients and written clearance from the scientific and ethical committee. Twenty patients who had compound fractures were available for evaluation. The duration of follow-up ranged from 6 to 12 months (average 8 months). The open fractures were classified according to the system of Gustilo–Anderson.[9] On admission, the general condition of the patient was assessed with regard to hypovolemia and associated orthopedic or other systemic injuries, and resuscitative measures were taken accordingly. All patients received analgesics in the form of intramuscular (IM) injections, tetglob 500 I.U IM, and intravenous (IV) antibiotics. A thorough clinical examination was performed including detailed history relating to age, sex, occupation, mode of injury, and past and associated medical illness. Patients were taken to the operating room for emergency irrigation and debridement of the open fracture. Swabs were taken from the wound and were sent for culture and sensitivity, thorough saline wash was given to the wound, and all the foreign bodies over the wound were washed out. A severity of the open fractures determined the subsequent wound care and antibiotic treatment. Wounds were examined and primary closure was done for the wounds presenting within 6 h of trauma and which were clean. A sterile dressing was given for wounds, and the limb was immobilized in the form of above-knee Plaster of Paris slab. Limb elevation over a pillow was given for all the patients. Routine investigations were done for all the patients. All patients were evaluated clinically and radiographically to assess for any other injuries. Radiographs were taken in two planes, anteroposterior (AP) and lateral views. IV antibiotics, cephalosporins, and aminoglycosides were started for all patients. Patients were operated as early as possible, once the general condition of the patients was stable and fit for surgery. Preoperatively, correct length of the nails was measured from the opposite leg. The length of the unreamed solid nail was calculated by the measurement taken from tibial tuberosity to the tip of the medial malleous, and medullary canal diameter was measured at the isthmus from the radiographs. Accordingly, a stock of the nails 2 cm above and below the measured length and 1 mm above and below the measured diameter was always kept. AP alignment was determined by measuring the angle between a line parallel to the proximal fragment and a line parallel to the distal fragment on lateral radiographs. Varus–valgus alignment was determined by measuring the angle between the lines drawn perpendicular to and bisecting the tibial plateau and proximal medullary canal, with a line bisecting the distal medullary canal and tibial plafond on AP radiographs. We defined excellent reduction as <2 mm of fracture gap and ≤5° of angulatory deformity in any plane (valgus/varus, or anterior/posterior). Good reduction was regarded as 2–5 mm of fracture gap and ≤5° of angulatory deformity in any plane. Poor reduction was regarded as >5 mm of fracture gap or >5° of angulatory deformity in any plane. Adequate reduction included excellent and good reductions. Bony union was defined by the presence of bridging callus on two radiographic views and the ability of patients to bear full weight on the injured extremity if other injuries allowed. Malunion was defined as angulation in coronal plane (varus/valgus) of >5°, sagittal plane (anterior/posterior) angulation >10°, or >1 cm shortening. Nonunion was defined as no evidence of healing after 6 months.[10] Inclusion criteria included fresh open fractures of tibia; adult patients ≥16 years of age; compound Type I, II, IIIA, and IIIB as per Gustilo–Anderson classification; and fractures at least 7 cm from the knee and ankle joints.[11] Patients with pathological fractures, children with fractures, and patients with associated head injury and chest and abdominal trauma necessitating delay in primary and immediate fixation were excluded from the study. Parameters to be studied were clinical examination and laboratory investigation to assess the eradication of infection, periodical clinical and radiological examination to assess the rate of bony union, and clinical examination to assess the functional return of the limb.

Surgical technique: Patients were operated under spinal/general anesthesia. Patient was placed in supine over a radiolucent operating table. Vertical medial parapatellar incision extending from the inferior pole of the patella to the tibial tuberosity was used. Patellar tendon was retracted laterally to determine the point of insertion which is essential for the success of the procedure. After selecting the point of insertion, a curved bone awl was used to breach the proximal tibial cortex in a curved manner. Reduction was done under image guidance in both AP and lateral views and then nail of an appropriate size was introduced. Following this, proximal and distal locking was done. The incised wound was washed with betadine and normal saline, and the incision was sutured in layers. Sterile dressing was applied over the wound, and compression bandage was given. All patients were administered 7 days of IV antibiotic and 2–3 weeks of oral antibiotics postoperatively based on their culture and sensitivity reports. Postoperative dressing was done at the 2nd day and at the 5th–7th days. Stitches were removed at the 14th day. All patients were advised to start partial weight bearing with two axillary crutches till adequate pain relief was achieved. Advice regarding full weight bearing was given on the basis of fracture type and the stability of the fracture fixation. Gentle joint mobilization exercises and muscle strengthening exercises were advised as soon as the patient became comfortable. Patients were usually followed up at 4 weeks, 6 weeks, 12 weeks, 18 weeks, and 24 weeks. On each occasion status of union, functional evaluation and complication, if any, was assessed in the following manner. Patients were asked about any subjective complaints such as pain, swelling, range of movements, loss of function, and weight bearing.[12] Movements of knee, ankle, and foot were checked. Standard AP and lateral X-ray was taken to assess the radiological union [Figure 1]. Any complication such as infection and implant failure in any form was checked. The final outcome of limb was assessed in accordance with the Johner and Wruh's criteria with modification.[13]
Figure 1: Unreamed solid interlocking nail in a patient at preoperative period, postoperative period, and at follow-up. (a) Preoperative anteroposterior and lateral view. (b) Postoperative anteroposterior and lateral view. (c) Postoperative 12 weeks. (d) Postoperative 24 weeks

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  Results Top


All the patients of 16 years or above age were included in this study. The mean age of the patients was 37.10 years, with a standard deviation of 10.50 years. Most of the patients were young adults. There were 18 male patients and 2 female patients. The mode of injury was road traffic accidents (RTA) in 15 patients followed by fall from height in five patients. There were 12 right-sided compound tibial fractures and 8 left-sided compound tibial fractures in our study. Out of twenty patients, two patients had compound Grade I injury, four patients had Grade II injury, 13 patients had Grade IIIA, and 1 had Grade IIIB injury. The most common fracture pattern was transverse in 9 cases, followed by comminuted in 8 cases, oblique in 2 cases, and 1 case of spiral fracture. There were 17 patients with compound fracture in the middle 1/3rd of tibia and three patients with compound fracture of the distal 1/3rd of tibia. Out of the twenty patients, four patients had associated injuries. Two patients had head injury, one patient had chest injury, and one patient had contralateral knee injury. In the present series, duration between injury and surgery varied from being operated after 8 h to 32 h. The mean injury surgery interval was 14.45 h, with a standard deviation of 5.84 h. The operating time range was from 45 to 90 min, and the mean operating time was 58.00 min, with a standard deviation of 10.18 min. All patients with compound Type IIIB fracture underwent flap surgery within 5 days of primary surgery and one patient with compound Type IIIA underwent split-skin grafting at 10th day of primary surgery. The mean partial weight bearing time was 2.70 weeks with a standard deviation of 0.57 weeks and the mean full weight bearing time was 11 weeks with a standard deviation of 1.38 weeks. Only one case (5%) had more than 25° restriction of ankle range of motion and 3 cases (15%) had <25° restriction of ankle range of motion. Only one case (5%) had more than 10° restriction of knee range of motion and two cases (10%) had <10° restriction of knee range of motion [Figure 2]. Two patients developed infection postoperatively and one patient had minimum neurovascular injury. One patient had 5° of varus/valgus angulation and one patient had 5° of anterior/posterior deformity. None of the patients had more than 5°of varus/valgus or anterior/posterior deformity. One patients had 1 cm shortening and four patients complained sporadic pain at fracture site, anterior knee pain, or ankle pain. Out of the four patients, two patients had occasional pain on exertion and two patients had moderate pain. One patient had mild limping on walking. In two cases, superficial infection was developed and was controlled by oral antibiotics. We found one case of nonunion without infection that was treated with Reamed nailing with bone grafting. Delayed union was reported in 2 cases; it was counteracted by dynamization. The mean union time was 22.53 weeks with a standard deviation of 5.69, and the range of union time was 18–36 weeks. We found excellent results in 13 cases, good in 4 cases, fair in 2 cases, and 1 had poor results.
Figure 2: Functional outcome of a patient in 24 weeks. (a) Full dorsiflexion at ankle. (b) Full plantar flexion at ankle. (c) Full flexion at knee. (d) Sitting cross leg. (e) Squatting. (f) Full weight bearing

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  Discussion Top


The management of open tibial fractures continues to be a challenge for most of the orthopedic surgeons. These fractures are usually caused by high-energy trauma, having numerous problems resulting from poor soft-tissue coverage and limited vascular supply of the tibia leading to nonunion, infection, malunion, and sometimes resulting in amputation.[14] Recent improvements in wound coverage techniques and fixation devices have decreased the prevalence of these complications, but the optimum management of open fractures of the tibial shaft is still evolving. There are two major factors related to the lesion that alter the final outcome of tibial shaft fractures. The first is the severity of the fracture, characterized according to Nicoll[2] by the degree of initial displacement, communition, and soft-tissue injury. Accordingly, the more severe the fracture, the higher the rate of complications and the longer the periods of healing will be whatever the method of fixation was used. The second factor is the damage of the tibial blood supply. In fractures of tibia, which has deficient soft-tissue coverage, not only is the endosteal circulation disrupted, but also periosteal circulation gets disrupted after severe soft-tissue damage and periosteal stripping from the bone. This emphasizes the necessity to preserve as much as possible the vascularity of the endosteal vessels, using stabilization techniques that avoid additional disruption of this blood supply. Intramedullary fixation by virtue of acting like an internal splint results in a stable fixation with secondary bony healing with external callus formation. Its major advantage lies in the fact that it is inserted in a closed fashion, thus minimizing trauma to the already traumatized soft tissues surrounding the fracture site. Furthermore, being a load-sharing device, it prevents stress shielding and reduces the rate of refractures. Until recently, all the intramedullary nailing involved reaming, but undoubtedly, reaming provides wider and uniform medullary cavity to insert a bigger diameter nail, which closely and snuggly fits into the medullary cavity, providing a stable fixation. But of late, the reports of hazardous consequences of reaming have come to light. Some of them include fat embolism, destruction of endosteal blood supply,[7] and higher infection rate in case of open tibial fracture. Studies have shown early revascularization, less bone grafting rate, less reduction to cortical circulation, and consequently less complications such as infection and compartment syndrome in unreamed nail. The purpose of this study work was to evaluate and compare the results of this study with that of previous studies in the treatment of compound tibial fractures. Majority of patients were between 20 and 60 years of age, and the mean age of the patients was 37.10 years, with a standard deviation of 10.50 years. Thus, we can overemphasize the fact that the younger and economically productive segment of our society sustains these fractures. In Greitbauer et al.'s series,[15] the patients' mean age was 39 years ranging from 15 to 84 years, whereas in Joshi et al.'s series,[16] the patients' mean age was 30 years (range 16–72 years). In Sakaki et al.'s series,[17] there was a large number of young patients (average age 32.75 years), in Singh et al.'s series,[18] 63.3% of patients were in the age group of 21–40 years, in Abdelaal and Kareem's series,[6] the patients' age ranged between 25 and 65 years with a mean age of 33.3 years, and in Gaurav and Agrawal's series,[19] patients' age group ranged from 20 to 46 years (average 32.17). The majority of the patients were males (total 15 cases [75%]), and the high incidence of males involved in RTA may be the reason for male predominance. In Greitbauer et al.'s (1998) series, 63% were males and 37% were females, in Joshi et al.'s (2004) series, 92.85% were males and 7.14% were females, in Sakaki et al.'s (2007) series, majority of the patients were males (95%) when compared to females (5%), in Singh et al.'s (2009) series, 87% were males and 13% were females, in Abdelaal et al.'s (2014) series, 80% were males and 20% were females, and Gaurav et al.'s (2017) series had more cases of male patients than females (82.5% vs. 17.5%). In our study, RTA was the mode of injury in maximum number of cases (75%) followed by fall from height (25%). In Greitbauer et al.'s (1998) series, 90% of the fractures were caused by RTA and 10% by fall from height; in Joshi et al.'s (2004) series, RTAs were the cause of fractures in all patients; in Sakaki et al.'s (2007) series, 84.1% were caused by RTA; in Singh et al.'s (2009) series, 80% were caused by RTA, 10% by fall from height, 6.6% by blow/assault, and 3.3% by crush injury; in Abdelaal et al.'s (2014) series, the causative trauma was motor car accident in 45.5% of cases, fall from height in 34.5% of cases, direct trauma by heavy object in 16.4% of cases, and 3.6% caused by gunshot injury. In Gaurav et al.'s (2017) series, majority of the fractures were due to RTAs (87.5%), while 7.5% were due to fall from height and 5% due to assault. In our series, 20% cases (10% head injury, 5% contralateral knee injury, and 5% chest injury) had associated injuries; in Joshi et al.'s (2004) series, fracture associated with head and chest and major nerve vessel injury were excluded from study; in Sakaki et al.'s (2007) series, 37.5% of cases had associated injuries and 45% of cases had associated injuries in the unreamed group; in Singh et al.'s (2009) series, 10% of the patients had associated injuries, with one case each of contralateral fracture leg, contralateral fracture femur, and clavicular fracture; and in Abdelaal et al.'s (2014) series, 14.5% had associated muscle skeletal injuries (femur fractures and colles fracture). In our study, 85% of patients (17) had middle-third shaft of tibia fracture and 15% (3) patients had distal shaft fractures; in Joshi et al.'s (2004) series, 64.28% of cases were at the mid-shaft level and 35.71% were at the positions of either the upper one-third or the lower one-third of tibia; in Singh et al.'s (2009) series, 66.6% of fractures were in the middle third, 23.3% in the lower third, and 10% occurred in the upper third of tibial shaft; and in Abdelaal et al.'s (2014) series, the upper third was affected in 20% of cases, middle third in 63.6% of cases, and lower third in 16.4% of cases. In our study, the most common fracture pattern was transverse in 9 cases (45%), followed by comminuted in 8 cases (40%), oblique in 2 cases (10%), and 1 case (5%) of spiral fracture. In Joshi et al.'s (2004) series, the most common pattern was transverse (62.5%) followed by comminuted (17.85%), short oblique (10.71%), and spiral (8.92%); in Singh et al.'s (2009) series, most of the fractures were transverse (36.6%) followed by oblique (23.3%), spiral (23.5%), and comminuted (16.6%); and in Abdelaal et al.'s (2014) series, the fractures were simple in 61.8% of cases and comminuted in 38.2% of cases. In our study, we included compound Grade I (two cases[10%]), Grade II (four cases[20%]), Grade IIIA (13 cases [65%]), and Grade IIIB (one case [5%]) fractures; in Joshi et al.'s (2004) series, there were 53.6% of Type I, 32.1% of Type II, 7.1% of Type IIIA, and 7.1% of Type IIIB fractures; in Sakaki et al.'s (2007) series, 25% patients were with Type I injury and 10% patients were with Type II injury; in Singh et al.'s (2009) series, 15 patients (50%) were with Type I injury, 11 patients (36.67%) with Type II, and two patients (6.67%) in each Type IIIA and Type IIIB; and in Abdelaal et al.'s (2014) series, 30.9% patients were with Type I, 30.9% with Type II, 25.45% with Type IIIA, and 12.72% with Type IIIA. In our study, the mean partial weight bearing time was 2.70 weeks, with a standard deviation of 0.57 weeks, and the mean full weight bearing time was 11 weeks with a standard deviation of 1.38 weeks. In Joshi et al.'s (2004) series, all patients were kept nonweight bearing until the formation of callus. In the present study, the mean nonweight bearing period was 8.2 weeks (range 6–14 weeks) and the mean partial weight bearing period was 8.2 weeks (range 6–20 weeks) and in Sakaki et al.'s (2007) series, patients were maintained on a short cast for 10 days. The operated limb was relieved of weight for the first 4 weeks after surgery and then allowed partial weight with crutches until union; in Singh et al.'s (2009) series, all cases were routinely immobilized in an above-knee pop slab till active dorsiflexion of the foot was possible, usually by the second/third day. Twenty-three patients (76.6%) started partial weight bearing by the end of the 3rd week, five patients by the end of the 6th week, and two patients by the end of 8 weeks. In a series by Kumar et al. (2010), 75% of patients started full weight bearing without support in 11–20 weeks, and in Gaurav et al.'s (2017) series, the average time to full weight bearing was 9.69 weeks, ranging from 8 to 12 weeks. In our study, duration between injury and surgery varied from 8 h to 32 h. The mean injury surgery interval was 14.45 h with a standard deviation of 5.84. This period of delay was utilized toward making the patient fit for surgery besides management of wounds in open fractures. In Joshi et al.'s (2004) series, the mean time interval from injury to surgery was 24 h (range 8–48 h); in Sakaki et al.'s (2007) series, most of the patients were operated within 24 h; in Singh et al.'s (2009) series, most of the patients were operated in 12–24 h of injury and 7% of patients were operated after 24 h; and in Abdelaal et al.'s (2014) series, 21.8% of cases were operated within 12 h, 36.37% cases in 24 h, 11% cases delayed for 72 h due to some other medical problems, and 9% cases delayed between 7 and 15 days. In our study, duration of surgery ranged from 45 to 90 min. The mean duration was 58 min with a standard deviation of 10.18 min; in Joshi et al.'s (2004) series, the mean operating time was 1 h (range 45–90 min); in Sakaki et al.'s (2007) series, the mean duration of surgery was 52 min; and in Singh et al.'s (2009) series, the mean operating time was 50 min (range 30–90 min). Healing was assessed to have occurred when the fractures were clinically stable and did not elicit pain on palpation, manual stress, or weight bearing[20]. In our study, the union time was 22.53 weeks with a standard deviation of 5.69 weeks. Union time was compared with grade of fractures [Table 1]. Union time was higher in Grade IIIA (24.31 weeks with a standard deviation of 6.10 weeks) and in Grade IIIB (20 weeks with a standard deviation of 0 week) as compared to Grade I (18 weeks) and Grade II fractures (18.67 weeks with standard deviation of 1.16 weeks). The severity of the associated soft-tissue injury was found to prolong the healing time of fracture [Table 2]. Final evaluation of patients was done as per Johner and Wruh's criteria, 1983, with modification. In our study, we did not find any significant joint stiffness that affected the activities of daily living. All the parameters were near normal as compared with the other series of ILNs. Only one case (5%) had more than 25° restriction of ankle range of motion and three cases (15%) had <25° restriction of ankle range of motion. Only one case (5%) had more than 10° restriction of knee range of motion and two cases (10%) had <10° restriction of knee range of motion. In our series, only one patient (5%) had 1 cm shortening; in Sakaki et al.'s (2007) series, mean shortening of 4.20 with standard deviation of 6.33 was observed; in Singh et al.'s (2009) series, shortening of more than 1 cm was noted in 3.33% cases; and in Abdelaal et al.'s (2014) series, <3 cm shortening was noted in 29.1% of cases, <4 cm were in 3.6% cases, and more than 4 cm in 3.6% cases. In our series, one patient (5%) had 5° of varus/valgus angulation and one patient (5%) had 5° of anterior/posterior angulation, and in Abdelaal et al.'s (2014) series, <15° angular deformity was seen in 29.1% cases, 15° 19° was seen in 3.6% cases, and more than 20° in 3.6% cases. In our series, two cases (10%) had occasional pain on exertion and two cases (10%) had moderate pain. In our series, the incidence of delayed union was in two cases (10%) and the incidence of nonunion was in one case (5%), and one case (5%) had mild limping while walking. In Singh et al.'s (2009) series, 6.6% of cases required skin grafting due to sloughing of skin. Among 16 statically locked cases, dynamization was done in six patients (20%) at an average of 14 weeks (range 12–16 weeks), Gaurav et al.'s (2017) series had superficial infections in 12.5%, knee stiffness in 15%, screw breakage in 5%, and infected non-unions in 10%. Final results of our study are comparable to those of the literature [Table 3].
Table 1: Union time compared with different studies

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Table 2: Union time (weeks) in compound Grade I, II, IIIA, and IIIB

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Table 3: Final outcome of our study compared with different studies

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  Conclusion Top


Unreamed solid interlocking nailing is considered a good method for the management of compound tibial fractures (Grade I–IIIB) as it allows early weight bearing, high rate of union with low complication rate, minimizes the chances of infection, achieves anatomical alignment, and allows early return to independent function. Operative care of the soft-tissue wound is critical in the treatment of open fractures.

Informed consent

Informed consent was obtained from all patients and ethical clearance was obtained from the institution's scientific and ethical committee.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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