Locking Intramedullary Nailing with Primary Soft Tissue Reconstruction in High Grade Open Tibial Fractures

Jawahar, S (2008) Locking Intramedullary Nailing with Primary Soft Tissue Reconstruction in High Grade Open Tibial Fractures. Masters thesis, Madurai Medical College, Madurai.

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Abstract

INTRODUCTION: A severe open tibial fracture is the result of high energy violence. The operative management is complex, time consuming and considered by many to create a significant morbidity. Many of the problems are related to the unique anatomy of tibia with its vulnerable soft tissue envelope. The type of treatment depends on the individual characteristics of the fracture and the concomitant soft tissue injury making experience and clinical judgement an important part of overall treatment. The established management of severe open tibial fracture is based on a philosophy of initial wound debridement and lavage, stabilization of fracture with external fixation and delayed wound closure. Debridement may need repeating because of the difficulty assessing tissue viability. Soft tissue cover is delayed to allow for a healthy wound bed. AIMS AND OBJECTIVES: 1. To study the anatomical and functional outcome of management of open tibial fractures with locking intramedullary nailing and primary soft tissue reconstruction. 2. To do a prospective, randomized, control study comparing the outcomes of locking intramedullary nailing and primary soft tissue reconstruction with that of external fixation and delayed soft tissue reconstruction. 3. To study the various methods of soft tissue reconstruction. MATERIALS AND METHODS: All adult patients, who were seen at Government Rajaji Hospital, Madurai because of an open fracture of the tibial diaphysis between July 2005 and July 2007 were evaluated for inclusion in the present study. Approval from the hospital ethics committee was obtained before the investigation was begun, and the patients gave informed consent before they were entered into the study. Criteria for selection of patients; Inclusion Criteria - 1. Age more than 20 yrs 2. Presenting within 24 hours of injury 3. High grade open tibial diaphyseal fractures (Grade IIIA, III B) 4. Primarily reconstructable soft tissue injury. Exclusion criteria - 1. Open growth plates 2. Intraarticular fractures extending into upper or lower end of tibia. 3. Fractures in the proximal fourth of tibia or fracture within four centimeters of the ankle, neither of which was judged to be amenable to intramedullary nailing 4. Grade III C fractures 5. Grossly contaminated and damaged wound. 6. Refusal for inclusion in the study 41 patients who have sustained high grade (Gustilo Anderson III A and III B) open tibial fractures fitting in the inclusion criteria entered into the study (36 males and 5 females). Their mean age was 33.95. The most common mode of injury was road traffic accidents. They were randomly allotted into study (interlocking nailing and primary soft tissue reconstruction) and control (external fixation and delayed soft tissue cover). About 4 patients lost for follow up, and the study conducted among the 37 patients. RESULTS: The mean age is 33.95% indicating high incidence of these fractures in productive age group and range is from 24 to 58. There is high incidence of these fractures in males. There is a significant difference between the study group and control group with regard to number of days of stay in the hospital and number of secondary procedures. There is no statistically significant difference between the occurrence of superficial infection in study and control group. The high incidence of deep infection in control group is statistically significant. The incidence of flap necrosis is statistically insignificant. There is statistically significantly high incidence of nonunion and malunion is control group. There is statically significant delay in the bony union of control group as compared to that of the study group. CONCLUSION: Open tibial shaft fractures represent a severe and complex problem and optimal management is essential if the patient is to regain significant preinjury level of functions. Soft tissue management including emergent irrigation and debridement of the wound and administration of antibiotics are of utmost importance in the treatment of these fractures. High union rates, low incidence of complications including infection and good functional results suggests that primary interlocking nailing and soft tissue reconstruction is a safe and effective technique for high grade open tibial fractures. Modern techniques of management combining the skills of experienced orthopaedic and plastic surgeons can consistency restore excellent limb function in a very high proportion of patients.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Locking Intramedullary Nailing ; Primary Soft Tissue Reconstruction ; High Grade Open Tibial Fractures.
Subjects: MEDICAL > Orthopaedics
Depositing User: Subramani R
Date Deposited: 16 Sep 2017 15:23
Last Modified: 17 Sep 2017 05:01
URI: http://repository-tnmgrmu.ac.in/id/eprint/2937

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