Nailing compound fractureswhen / safety evidence

DR.G.S.KULKARNI MIRAJ

HISTORY of open fractures• American Civil War

Mortality 26% • France – Russian war

13000 Amputee

Nailing in open fractures

1. Improved technique debridement.2. Use of AB bead pouch and Rod3. Vaccume assisted closure4. Newer designs of nails & plates.5. Perioper. AB

Corner stone of Open fracture-Debridement

1. Wound - Extend longitudinally-2. Exploration Fasciotomy3. Debridement4. Irrigation 5. AB Beads 6. VAC – not a substitute

Adv. nailing in open #1. Early stabilization of open fracture

controls pain,swelling, mobility

inflammation2. Mobility-Further soft tissue damage3. Early mobilization of jt & pt. 4 CPM

IMN Adv.1.Biomechanically superior,

maintain L, alignment and rotation

2.Early wt. bearing3.Less rate of secondary surgery

Adv. of immediate IF

Unkinks A,V and lymphatics , improves circulation at fracture zone

Ext. Fix –meta-analysisAdv : union - 94 % infection - 16% chro. Osteo - 4% -Giamondis JBJS, Br. 2006

Complication of Ext. Fix1. Pin loosening2. Pin tract inf. 32 %3. Mal-union 4. Exchange nailing- inf -- 15 to 30%5. “Non-union machine “

IMNIMN is a safe, effective method

for open fracture I, II, III A & B S.Malvin JAAOS, Feb 2010

Reamed V/s Unreamed

• Reaminng-- Adv 1. larger diameter – better fracture stability 2. Implant failure less 3. Reaming deposit B.G.

4. Periosteal blood supply ++

Reaming .• Metaanalysis failed to show an

increased risk of re-operation• No increased rate of infection or

nonunion - Bhandari Et al

JBJS B 2001 : 62 - 68

Multicentric level 1 study• open fractures 460 • Reamed 210• Unreamed 196• Does not support superiority of either. SPRINT Group JBJS Am 2008 Debate is ongoing

• Reamed Disadv - 1. Reduced intramedullary blood supply, but Periosteal blood supply ++

2. Thermal necrosisa) use sharp reamers, increment

by 0.5 mm b) gentle reaming –back & forth

Poor result of IMN1. Inadequate debridement2. Inappropriate soft tissue closure3. Thermal necrosis4. Severe contamination + late arrival These are contra-indications

Literature • 143 cases of open tibial shaft

fractures.Primary IMN has Favourable results.• Deep infection – 3 % - Koker & Tornetta JOT 2007

Exchange ex fix to IMN

• Safety period 10 days till soft tissue recovery

• < 14 days ( Varies from 7 to 28 days)• Shorter period reduces infection rate

- JS Melion et al JOT Feb 2010

Do not do primary IMN• Severe contamination• Inadequate debridement• Delayed arrival• AB Rod + Ex. Fix • 7-10 days IMN

JAGRUTI M

DAY 1Debride A-B Rod AO Ex Fix 1st VAC

JAGRUTI MANCHAREKAR

DAY 1

DAY 5

JAGRUTI M

After 3 changes of VAC, 2nd Skin graft

DAY 9

JAGRUTI M

After 1 yr

VAC & I.F. OF OPEN FRACTURE

• With VAC it is possible to nail or plate IIIB open #

as VAC is an excellent interval coverage

• Almost no role of plaster splint or plaster cast with window in open fracture.

External Fixator in Open #s• Advantages 1. Pins away from fracture zone 2. No additional open surgery 3. Access to wound dressing and plastic surgery 4. Early mobilisation

External Fixator• Disadvantages :1. Pin tract infection2. Risk of infection of later ORIF3. Soft – tissue impaling stiff jt.4. Pin loosening Ex fix as a definative treat not

favoured

AC

VAC

Nailed on day 1 of injury

Amar Sawant

15 days old

AMAR SAWANTAmar Sawant

AMAR SAWANTAmar Sawant

Amar Sawant 146213

Chavan chandrakant - 153242

Chavan chandrakant - 153242

Kolekar Parmeshwar - 146071

Hebbal Hasan 142617

Open fracture+ pilon IMN on day 1

Hebbal Hasan 142617

Both united

CONCLUSION

• Corner stone of fracture debridement• IMN is a safe, effective method • Two stage nailing –I) AB rod II) ILIMN

a) severe contaminationb) delayed arrival