Dear Ashok

I prefer Reamed IM Nail in the open fracture of tibia. In the actual literature the Reamed IM Nail when compared with Unreamed IM Nail in the treatment of open fractures of tibia , the results were similar with respect to complications rates. The healing time is faster and there is less breakage of the locking screws in the Reamed IM Nail.

Surgeon,s choice. Whichever technique you do respect biology.

in open fractures of the tibia, I use the intramedullary nail within the first 6 hours after the trauma. After six hours of injury, I use an external fixator, Montoro clinical conditions and after 2 weeks I insert an intramedullary nail (if there are no signs of clinical infection and blood indices)

Dear Ashok,

I know that there are no definite answers in literature to solve this issue. I always used reamed T2 nail from stryker, also in open fractures (till gr. II of Gustilo classification) within 6 hours after trauma; otherwise I used external fixation and delayed nailing. I had no problem with infections or non-union. Anyway I personally think that grade of exposure, general and local risk factors of the patient and time for surgery are crucial in outcome, maybe more than type of fixation.

Regards

Thank You.

The decision certainly also depends on the accompanying injuries, since reaming has been shown to increase the risk for pulmonary (or even cerebral) fat embolism. It further depends on fracture characteristics and stability. In case of some C-type fractures with a comminuted zone you might sometimes not improve stability by reaming, and nailing without reaming is faster.

I would opt for a reamed nail. If the patient is physiologically unwell, and I was employing a Damage Control approach, then temporising external fixation would be my choice. At the time of definitive fixation, the patient should be physiologically well enough to tolerate reaming, and therefore I would opt for the reamed nail. The larger diameter, especially of the locking bolts, is beneficial, along with the faster union rate. I am not sure that I would use unreamed nails in my practice even in the emergency situation. Ex fix is less physiologically challenging for the patient. Even an unreamed nail shows increased intramedullary pressures when instrumenting the canal....

Dear Ashok,

what do you mean with "open fracture"?

The good, the bad, the ugly or the rotten?

After appropriate debridement, reaming will improve bone healing. This is only my personal opinion, However, you´ll find some aspects supporting this idea in the metaanalysis by Zhou Xiang.

In the case of the ugly and the rotten fractures you have to make you decision after an initial ExFix depending on the soft tissue condition. The risk of deep infection will be higher in reamed nails, but it´s not impossible...

Dear Alexander,

I am eager to know your Suggestions for the selection of different Treatment options in 'THE GOOD', 'THE BAD', 'THE UGLY' AND 'THE ROTTEN' Open fractures.

Thank You.

Dear Yongshen,

Indeed, Dr Alexander is very insightful and I do like his Good, Bad, Ugly and Rotten Analogy. Yes, it was something I could have mentioned precisely.

And Thank you very much for your suggestions and particularly The BAPRAS Guidelines which I was unaware of.

Million Thanks.

I prefer reamed IMN

Dear Ashok,

to amend the insightful suggestions of Dr. Chen I suggest you also to read the papers of S. Rajasekaran (Ganga Hospital, Coimbatore, South India) who was the first I know to use this analogy. He and his colleagues defined some important criteria for soft tissue management in Gustilo IIIa-b injuries (fix and close, fix and flap, fix and wait and flap etc), which are very helpful for my personal decision making. Look also at the papers about the Ganga-Hospital Score (I can send you some pdf)

Regards

Dear Alexander,

I really appreciate your concern. Many many thanks.

It would be very nice of you if you could send me those pdf.

I will surely send a mail to you.

Million thanks for your help.

Regards.

I personally treat all open tibial fractures with immediate definitive circular external fixation; The degree of soft tissue damage at the fracture site is high, and following the rules of primum non nocere recognise that a frame is the most supportive environment for the soft tissue injury to heal in. It relies on minimally invasive fixation distant to the injury site, permits immediate weight bearing and rehabilitation, does not require re-operation routinely, and furthermore, does not increase the risk of infection at the fracture site. As a limb reconstruction surgeon, I believe infected plate or nail osteosynthesis to be a dreadful (and avoidable) complication which often requires major surgical intervention and prolonged treatment to address.

Currently, reaming of canal is becoming less popular with the introduction of locked intramedular nails. When using thiese implants the primary stability (incl. rotational) is good enough. In this way the adverse effects of reaming (damage to endosteal blood supply, risk for pulmonary embolism, etc) are reduced. Of course, in patients with severe Gustilo grades the external fixation is recommended.

Personally, I treat these with reamed, locked intramedullary nail. I think the most important factor in preventing infection and promoting healing is early definitive soft tissue coverage of the bone.

That said, I think Matt Fletcher has a great point about definitive treatment with circular external fixation. If I were more comfortable with this technique (I am an Ortho Oncologist and only manage trauma when on call), I would make this my preferred technique for "bad" and "ugly" open tibial fractures.

Dear Panayot and William Thank You.

Dear Ashok, what about platting? I have vary good results with locking plates even with sever soft tissue damage. Itay

Dr.Inay Fenichel, I am sorry to express an opposite opinion as far as plating in cases with severe soft tissue damage is concerned. Do you excise the devitalized tissues ? Then plating ? And then, do you use skin grafting to cover soft-tissue- and skin defects ? Please, explain your protocol.

Dear. Panayot. I perform excision of the damaged tissue . I always try to cover the plate with the soft tissue. I use titanium locking plate. Sometime I need a plastic surgeon to mobilize the soft tissue and close the wound with skin graft.

As far as plating of long bobe fracture is concerned, it is a good idea to follow the "old good" AO principles. The plate should placed on the tension side of the bone. One of the exceprions to this biomechanically substantiated rule is the case when there is a severe soft-tissue and skin damage on this side. In similar cases the surgeon may go against the rule placing the plate on the compression side. In this way the complex solving of the soft-tissue problem will be avoided. Furthermore, the contemporary locked plates give enough primary stability on the compression side too.

Dear Itay,

Ruedi et al. reported 90% good functional result when treated with Plates but a complication rate of nearly 30%.

Also, nonunion was twice as common and infection five times more likely when open fractures were treated with plating.

However, delaying surgery for several days after injury resulted in fewer complications (infections in 6.4% and delayed union in 16.6%, when treated with variety of appliances 1-3 weeks after injury).

Thank You.

Personally, I recommend Less severe Open Tibial Fractures (Gustillo Type I & II) = Unreamed IM Nail. And Gustillo III Open Tibial Fractures = External Fixation.

Thank You.

We perform reamed IM nailing in open grade I to IIIA fractures. In IIIB we usually prefer an ex fix and, once achieved a good fracture coverage, we perform a secondary reamed IM nailing. We do not try to ream as much as we can to get the bigger possible diameter but we ream enough to use a 9 or 10 mm nail. We don't consider plating in diaphyseal open tibial fractures.

Gustilo I and II with fairly clean wound, interlocking nailing.

Hi. I feel whether early or late, the basic principle will remain debridement with unreamed solid tibial nail. Reamming will compromised the medullary blood supply further and plating will take away the vascular supply further.

In grade 1 and 2 open fractures, I always use a reasonably thick and well fitting nail with an aim to give good stability. I aim for 10 mm nail. Usually I ream. I have satisfactory results.

In grade 3 with soft tissue concerns, I do a good debridement and add an unreamed nail. After soft tissue cover, in about 25% cases, they failed to unite and I had to do an additional procedure of bone grafting with/ without exchange nailing (this time a reamed nail).

I give external fixator only in cases, where the contamination was so severe that I expect soft tissue problems.

I never use plating in tibia. I use it for open humerus and forearm.

No indication for plating in our field of experience. Grade III are treated by EXFIX with secondary nailing. Grade I & II are nailed. We do not ream as much as possible, usually one or two sizes less than expected on X-Rays...

I do not use unreamed nails due to unsatisafactory reduction.

Dear Dr. Levi-Faict, at the end reamed or unreamed nails ? Your posting is rather perplexing

Dear Colleague, at the end REAMED nails...

Thank you, Dr. Levi-Faict for your clear answer.