Primary Interlocking Nailing and Primary Soft Tissue Cover in Open Fractures of Tibia: A Prospective Study

Sivashanmugam, R (2008) Primary Interlocking Nailing and Primary Soft Tissue Cover in Open Fractures of Tibia: A Prospective Study. Masters thesis, Madras Medical College, Chennai.


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INTRODUCTION: The tibial shaft is one of the most common sites of an open fracture, a fracture that involves a break in the skin with soft tissues communicating with the fracture or its hematoma, or both. Because of the high prevalence of complications associated with these fractures, management often is difficult, and the optimum method of treatment remains a subject of controversy. About 23% of all tibial fractures are open and most of these are Gustilo grade III. Most of them due to road traffic accidents followed by fall, sports activities, blow / assault, gun shot injuries and other rare injuries like blasts. Open injuries of tibia are associated with twice the amount of contamination than other open fractures. With better understanding of the importance of serial wound debridement and early soft tissue cover for open fracture 18,20 good results have been achieved. Subcutaneous nature of the tibia makes the secondary reconstructive procedures difficult. But the advent of free flaps and advancement made in the micro-vascular techniques have led to reliable cover of traumatic musculocutaneous defects. Progressive refinement in the fixation of fractures and early bone grafting have resulted in a shorter time to union. The combined treatment of both the soft-tissue and skeletal components of severe open tibial fractures by dedicated teams commonly the orthopaedic-surgeon and plastic-surgeon has further improved outcomes and reduced morbidity. AIM: To evaluate the functional outcome of primary interlocking nailing and softtissue cover in open fractures of tibia in government hospital setup. MATERIALS AND METHODS: This study was done from February 2006 – November 2007, for a period of 22 months, in Department of Orthopedic Surgery, Madras Medical College & Government General Hospital, Chennai. We did primary interlocking nailing and immediate skin cover in 31 patients for 31 fractures. Out of these 31 patients, we have lost follow-up of 4 patients and we have analysed the results with the average follow-up of 12 months and minimum follow up of 5 months. Inclusion criteria - Any Gustilo and Anderson Grade II, III A and III B compound tibial fractures presenting to our institute within 48 hours of injury. Exclusion criteria - Patient presenting with more than 48 hours of injury. Grade I and Grade III C compound tibial fractures. Patients’ age ranged from 18 to 70 years. Average: 37. In our series, Male predominated with the ratio of 9:1. In our series, RTA was the predominant cause of injury. In RTA, 2 wheeler Vs 4 wheeler was the most common (10 cases). In our series, nearly half (45%) of the patients were referred from other hospitals. RESULTS: Type II Fractures - Union was observed in 11 of the 13 patients. The mean time to union was 27 weeks (range 20 weeks to 40 weeks). Dynamisation was done in 1 patient and Dynamisation followed by bone grafting was done in 1 patient. For infective non union seen in 1 patient posterolateral bone grafting was done and for non union in 1 patient bone grafting was done. Results of these patients were awaited. Type III A Fractures - Union was observed in 7 of the 10 patients. The mean time to union was 31 weeks (23-37 weeks). Prophylactic bone grafting was done in 1 patient. Aseptic nonunion was seen in 1 patient for which bone grafting13 was done. Infective non union was seen in 2 patients, for which antibiotic exchange nailing has been planned. Type III B Fractures - Two of the four type III B fractures united in average time of 47 weeks. Out of the 4 patients muscle flaps was done in 2 patients and fasciocutaneous flaps in 2 patients. 3 patients developed infection, for which appropriated anti biotics were given. CONCLUSION: Primary interlocking and primary closure produces excellent results in GrI and GrII fractures as compared to any other modality of treatment. For GrIII fractures infection rate was 35%, which is as good as external fixation but better than secondary nailing. Primary interlocking nailing and primary closure as a single staged procedure required less number of secondary procedures as compared to external fixation and secondary nailing. Functional outcome was far better in primary interlocking and primary closure than other procedures. Although the infection rates in GrIIIB fractures treated with primary interlocking was high this can be improved by better theatre sterility, early surgical intervention, timely secondary procedures and accurate assessment of soft tissue injury.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Primary Interlocking Nailing ; Primary Soft Tissue Cover ; Open Fractures of Tibia ; Prospective Study.
Subjects: MEDICAL > Orthopaedics
Depositing User: Subramani R
Date Deposited: 14 Sep 2017 02:20
Last Modified: 14 Sep 2017 02:20

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