Open Fractures of the Tibia Treated by Immediate Intramedullary Tibial Nail Insertion Without Reaming: A Prospective Study

Objective: Does immediate tibial nail insertion without reaming as part of protocol-driven management provide a safe and effective treatment for open tibia fractures? Study Design: Prospective cohort. Setting: Level 1 trauma center. Patients: A consecutive series of 161 patients with Gustilo grade I-IIIb open tibia fractures. Intervention: Emergent incision and debridement of the wound with immediate tibial nail insertion without reaming, repeat incision and debridement, and soft-tissue coverage within 14 days. Main Outcome Measurements: Time to union, number of secondary procedures performed to obtain union, implant failures, and the type and incidence of complications. Results: One hundred and forty-three fractures were followed to union. Follow up averaged 2.2 years (0.6-5.5 years). Seventy-six fractures united in less than 6 months, 35 took between 6 and 9 months, and 32 took longer than 9 months. Twenty-five additional procedures were needed to obtain union in 16 of the delayed unions (12 nail exchanges, 4 bone grafts, 9 dynamizations). Complications included 3 patients with cellulitis, 1 superficial infection, 4 deep infections (1 grade I, 2 grade II, 1 grade IIIb), 3 loose screws, 2 broken screws, 5 malunions greater than 5 degrees, and 30 patients with decreased ankle motion when compared with the uninjured side. Not counting the ankle loss of motion, 18 complications occurred in 143 fractures (13%). Twenty-nine patients (20%) had complaints of minor knee pain and 30 (21%) had occasional fracture site pain after activity despite clinical and radiographic evidence of union. Eleven patients (8%) considered themselves completely disabled. Five patients were not treated by the standard protocol and are not included in the previously listed statistics; 3 were grade IIIB that did not have adequate coverage by 14 days, and 2 were grade II injuries that did not have a second debridement. Four of these 5 patients developed a complication. Conclusions: Protocol-driven management emphasizing meticulous soft-tissue management and the use of immediate tibial nailing without reaming appears to be safe and effective in the treatment of open tibia fractures. The deep infection rate for the patients who were treated by protocol was 3% and the implant failure rate was lower than has been previously reported, most likely attributable to attempts to obtain cortical contact and avoid fracture gaps. Overall satisfaction was good, but approximately 41% of the patients had complaints of knee or fracture site pain or both well after union.