Incidence of infection after early intramedullary nailing of open tibial shaft fractures stabilized with external fixators

Garg Uttam Kumar; Shukla S.K.; Pathak S. K; Usmani I.A

Volume : IX, Issue : VII, July - 2020

Incidence of infection after early intramedullary nailing of open tibial shaft fractures stabilized with external fixators

Garg Uttam Kumar, Shukla S. K. , Pathak S. K, Usmani I. A

Abstract :

Thirty-two patients had a severe open fracture of the tibia that was initially treated by external fixation and subsequently by unreamed intramedullary nailing. The external fixation had been maintained for an average of sixty-one days (range, ten to 260 days). The mean interval between removal of the external fixator and intramedullary nailing was twenty-five days (range, 10 to 40 days). Eight out of twelve patients who had an infection at one or more of the pin sites, an infection later developed around the intramedullary nail. In comparison, only five of the twenty-five patients who had not had a pin-site infection had an infection later around the nail. An analysis of other variables, including the duration of external fixation, wound coverage, other injuries, and the type of fracture, showed that none was a predictor of infection either at the pin sites or around the intramedullary nail. We concluded that a pin-site infection that develops during external fixation is a contraindication to the subsequent use of unreamed intramedullary nailing in patients who have a fracture of the tibia. Background: Compound fractures of the shaft of tibia represent one of the most common lower extremity fractures. Definite intramedullary nailing of tibial shaft fracture after external fixation (EF) is controversial due to infection risk, which can be much. On the other hand, isolated EF management is also problematic. It also improves patient comfort (healing care, ankle rehabilitation) and may enable earlier return to work, if sedentary. It may be performed early (within 2 months of fracture), after a �damage control� phase, or later with a view to facilitating fusion. It remains a subject of debate, with varying reported rates of fusion and of infection. The present continuous retrospective series was therefore analysed to determine: Materials and Methods: We retrospectively reviewed 32 cases of open diaphyseal fractures of the tibia of varying severity that were managed at our institute from 2013 to 2019 with primary stabilization with tubular fixator. All the cases included in the study had a staged treatment (primary external fixation followed by intramedullary nailing) because of either delayed presentation or multiple associated injuries. Cases that had less than two-year follow-up were not included in the study. Once there were no signs of local wound infection (no swelling, erythema, or discharge), patients were allowed for definitive internal fixation with intramedullary nail. The present study therefore analyzed tibial shaft intramedullary nailing, to determine infection and union rates, and whether intramedullary nailing associated to external fixator ablation increased the risk of infection. Results: Fourteen patients (43.7%) in which one (16.7%) from Gustilo type I, five (35.7%) from Gustilo type II and eight (66.7%) from Gustilo IIIB injuries were developed intramedullary infection, in which three patients were cured by deidement and implant retention till the fracture union. Later on the implants were removed in two patients within two years of period. In Gustilo type I fractures, the average time to union was 20 weeks, whereas for Gustilo types II and III, it was 28 and 44 weeks, respectively. There were two cases of frank nonunion (6.25%), both followed by infection of the fracture site and loosening of the implant. There was one case of malunion which was treated with Ilizarav external ring fixator. Conclusion: Definite intramedullary nailing after external fixation is a controversial treatment option. Statistically, the sole factor significantly increasing infection risk was skin wound severity on the Gustilo classification. In Gustilo type IIIB and IIIC fracture, there are high rates of EF pin site infection. We concluded that a pin-site infection that develops during external fixation is a contraindication to the subsequent use of intramedullary nailing in patients who have a fracture of the tibia.