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European Journal of Trauma and Emergency Surgery

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01.02.2015 | Review Article

Intramedullary nailing after external fixation of the femur and tibia: a review of advantages and limits

verfasst von: P. Pairon, C. Ossendorf, S. Kuhn, A. Hofmann, P. M. Rommens

Erschienen in: European Journal of Trauma and Emergency Surgery | Ausgabe 1/2015

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Abstract

Purpose and methods

External fixation is a safe option for stabilisation of extremity lesions in the polytraumatised patient as well as in fractures with severe soft tissue damage. Nevertheless, long-term-complications are to be expected when external fixation is chosen as a definitive treatment. The purpose of this review article is twofold: primarily, to define the rationale of a procedural change from an external fixator to an intramedullary nail; secondarily, to assess the possible advantages and pitfalls of a single- or two-staged procedure.

Results and conclusions

External fixation of the femur is recommended in multiply injured patients who are critically ill to avoid an additional inflammatory response caused by the surgical trauma of primary nailing. The conversion towards nailing must be done as soon as the clinical condition of the patient has been stabilised. Stable polytraumatised patients do not benefit from initial stabilisation with an external fixator and should immediately be treated with a definitive osteosynthesis. In tibial fractures, external fixation followed by intramedullary nailing is recommendable in fractures with severe soft tissue injuries. Conversion should be done as soon as the soft tissues allow before pin-tract infections occur and performed in a one-staged procedure.

Pape HC, Grimme K, Van Griensven M, Sott AH, Giannoudis P, Morley J, et al. Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group. J Trauma. 2003;55(1):7–13. doi:10.1097/01.TA.0000075787.69695.4E.PubMedCrossRef

Pape HC, Schmidt RE, Rice J, van Griensven M, das Gupta R, Krettek C, et al. Biochemical changes after trauma and skeletal surgery of the lower extremity: quantification of the operative burden. Crit Care Med. 2000;28(10):3441–8.

Sun TS, Chen XB, Liu Z, Ma ZY, Zhang JZ. Relationship between the operation time of multiple fractures with system inflammation changes and clinical outcomes. Chin J Surg (Zhonghua wai ke za zhi). 2008;46(13):961–5.

Riemer BL, Sagiv S, Butterfield SL, Burke CJ 3rd. Tibial diaphyseal nonunions after external fixation treated with nonreamed solid core nails. Orthopedics. 1996;19(2):109–16.PubMed

Alonso J, Geissler W, Hughes JL. External fixation of femoral fractures. Indications and limitations. Clin Orthop Relat Res. 1989;241:83–8.PubMed

Dabezies EJ, D’Ambrosia R, Shoji H, Norris R, Murphy G. Fractures of the femoral shaft treated by external fixation with the Wagner device. J Bone Joint Surg Am. 1984;66(3):360–4.PubMed

Murphy CP, D’Ambrosia RD, Dabezies EJ, Acker JH, Shoji H, Chuinard RG. Complex femur fractures: treatment with the Wagner external fixation device or the Grosse–Kempf interlocking nail. J Trauma. 1988;28(11):1553–61.PubMedCrossRef

Rooser B, Bengtson S, Herrlin K, Onnerfalt R. External fixation of femoral fractures: experience with 15 cases. J Orthop Trauma. 1990;4(1):70–4.PubMedCrossRef

Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am. 1989;71(3):336–40.PubMed

10.

Brumback RJ, Uwagie-Ero S, Lakatos RP, Poka A, Bathon GH, Burgess AR. Intramedullary nailing of femoral shaft fractures. Part II: fracture-healing with static interlocking fixation. J Bone Joint Surg Am. 1988;70(10):1453–62.PubMed

11.

Phillips TF, Contreras DM. Timing of operative treatment of fractures in patients who have multiple injuries. J Bone Joint Surg Am. 1990;72(5):784–8.PubMed

12.

Tornetta P 3rd, Bergman M, Watnik N, Berkowitz G, Steuer J. Treatment of grade-IIIb open tibial fractures. A prospective randomised comparison of external fixation and non-reamed locked nailing. J Bone Joint Surg Br. 1994;76(1):13–9.PubMed

13.

Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am. 2000;82(6):781–8.PubMedCrossRef

14.

Giannoudis PV, Abbott C, Stone M, Bellamy MC, Smith RM. Fatal systemic inflammatory response syndrome following early bilateral femoral nailing. Intensive Care Med. 1998;24(6):641–2.PubMedCrossRef

15.

Giannoudis PV, Smith RM, Bellamy MC, Morrison JF, Dickson RA, Guillou PJ. Stimulation of the inflammatory system by reamed and unreamed nailing of femoral fractures. An analysis of the second hit. J Bone Joint Surg Br. 1999;81(2):356–61.PubMedCrossRef

16.

Giannoudis PV, Giannoudi M, Stavlas P. Damage control orthopaedics: lessons learned. Injury. 2009;40(Suppl 4):S47–52. doi:10.1016/j.injury.2009.10.036.PubMedCrossRef

17.

Trentz O. Management of patients with multiple injuries. Therapeutische Umschau Revue therapeutique. 1993;50(7):491–9.PubMed

18.

Krettek C, Simon RG, Tscherne H. Management priorities in patients with polytrauma. Langenbeck’s Arch Surg (Deutsche Gesellschaft fur Chirurgie). 1998;383(3–4):220–7.CrossRef

19.

Clifford RP, Lyons TJ, Webb JK. Complications of external fixation of open fractures of the tibia. Injury. 1987;18(3):174–6.PubMedCrossRef

20.

Rommens PM, Miserez MJ, Broos PL. Die Verriegelungsnagelung im Verfahrenswechsel nach Fixateur-externe-Osteosynthese an der unteren Extremitaet. Der Unfallchirurg. 1993;229:189–98.

21.

Rommens PM, Van Raemdonck DE, Broos PL. Reosteosynthesis of the tibial shaft. Part I. Changement of procedure after external fixation. Acta Chir Belg. 1989;89(5):281–6.PubMed

22.

Wu CC, Shih CH. Treatment of open femoral and tibial shaft fractures preliminary report on external fixation and secondary intramedullary nailing. J Formos Med Assoc (Taiwan yi zhi). 1991;90(12):1179–85.

23.

Schuh A, Hausel M. Our experiences with change of osteosynthesis from external fixator to internal fixation in fractures of the lower limb. Zentralbl Chir. 2003;128(8):674–9. doi:10.1055/s-2003-41374.PubMedCrossRef

24.

Sigurdsen UE, Reikeras O, Utvag SE. External fixation compared to intramedullary nailing of tibial fractures in the rat. Acta Orthop. 2009;80(3):375–9. doi:10.3109/17453670903035567.PubMedCentralPubMedCrossRef

25.

Rommens PM, Broos PL, Stappaerts K, Gruwez JA. Internal stabilization after external fixation of fractures of the shaft of the tibia: sense or nonsense? Injury. 1988;19(6):432–5.PubMedCrossRef

26.

Chao EY, Aro HT, Lewallen DG, Kelly PJ. The effect of rigidity on fracture healing in external fixation. Clin Orthop Relat Res. 1989;241:24–35.PubMed

27.

Moss DP, Tejwani NC. Biomechanics of external fixation: a review of the literature. Bull NYU Hosp Joint Dis. 2007;65(4):294–9.

28.

Kalfas IH. Principles of bone healing. Neurosurg Focus. 2001;10(4):E1.PubMedCrossRef

29.

Olson SA, Schemitsch EH. Open fractures of the tibial shaft: an update. Instr Course Lect. 2003;52:623–31.PubMed

30.

Templeman DC, Gulli B, Tsukayama DT, Gustilo RB. Update on the management of open fractures of the tibial shaft. Clin Orthop Relat Res. 1998;350:18–25.PubMedCrossRef

31.

Agrawal A, Chauhan VD, Maheshwari RK, Juyal AK. Primary nailing in the open fractures of the Tibia––is it worth? JCDR. 2013;7(6):1125–30. doi:10.7860/JCDR/2013/5504.3081.PubMedCentralPubMed

32.

Tielinen L, Lindahl JE, Tukiainen EJ. Acute unreamed intramedullary nailing and soft tissue reconstruction with muscle flaps for the treatment of severe open tibial shaft fractures. Injury. 2007;38(8):906–12. doi:10.1016/j.injury.2007.02.052.PubMedCrossRef

33.

Henley MB, Chapman JR, Agel J, Harvey EJ, Whorton AM, Swiontkowski MF. Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective comparison of unreamed interlocking intramedullary nails and half-pin external fixators. J Orthop Trauma. 1998;12(1):1–7.PubMedCrossRef

34.

Runkel M, Wenda K, Degreif J, Blum J. Results of primary unreamed tibial nailing of tibial fractures with severe open or closed soft tissue injuries. Der Unfallchirurg. 1996;99(10):771–7.PubMedCrossRef

35.

Ueno M, Yokoyama K, Nakamura K, Uchino M, Suzuki T, Itoman M. Early unreamed intramedullary nailing without a safety interval and simultaneous flap coverage following external fixation in type IIIB open tibial fractures: a report of four successful cases. Injury. 2006;37(3):289–94. doi:10.1016/j.injury.2005.08.018.PubMedCrossRef

36.

Alberts KA, Loohagen G, Einarsdottir H. Open tibial fractures: faster union after unreamed nailing than external fixation. Injury. 1999;30(8):519–23.PubMedCrossRef

37.

Shannon FJ, Mullett H, O’Rourke K. Unreamed intramedullary nail versus external fixation in grade III open tibial fractures. J Trauma. 2002;52(4):650–4.PubMedCrossRef

38.

Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 1999;13(2):78–84.PubMedCrossRef

39.

Della Rocca GJ, Crist BD. External fixation versus conversion to intramedullary nailing for definitive management of closed fractures of the femoral and tibial shaft. J Am Acad Orthop Surg. 2006;14(10 Spec No.):S131–5.

40.

Park HJ, Uchino M, Nakamura M, Ueno M, Kojima Y, Itoman M, et al. Immediate interlocking nailing versus external fixation followed by delayed interlocking nailing for Gustilo type IIIB open tibial fractures. J Orthop Surg. 2007;15(2):131–6.

41.

Melvin JS, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S. Open tibial shaft fractures: II. Definitive management and limb salvage. J Am Acad Orthop Surg. 2010;18(2):108–17.PubMed

42.

Melvin JS, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S. Open tibial shaft fractures: I. Evaluation and initial wound management. J Am Acad Orthop Surg. 2010;18(1):10–9.PubMed

43.

Borrelli J Jr. Management of soft tissue injuries associated with tibial plateau fractures. J Knee Surg. 2014;27(1):5–9. doi:10.1055/s-0033-1363546.PubMed

44.

Siebenrock KA, Schillig B, Jakob RP. Treatment of complex tibial shaft fractures. Arguments for early secondary intramedullary nailing. Clin Orthop Relat Res. 1993;290:269–74.PubMed

45.

Paderni S, Trentani P, Grippo G, Bianchi G, Squarzina PB, Tigani D. Intramedullary osteosynthesis after external fixation. La Chirurgia degli organi di movimento. 2001;86(3):183–90.PubMed

46.

Malik ZU, Hanif MS, Safdar A, Masood T. Planned external fixation to locked intramedullary nailing conversion for open fractures of shaft of femur and tibia. JCPSP. 2005;15(3):133–6 (pii:03.2005/JCPSP.133136).PubMed

47.

McGraw JM, Lim EV. Treatment of open tibial-shaft fractures. External fixation and secondary intramedullary nailing. J Bone Joint Surg Am. 1988;70(6):900–11.PubMed

48.

Blachut PA, Meek RN, O’Brien PJ. External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. A sequential protocol. J Bone Joint Surg Am. 1990;72(5):729–35.PubMed

49.

Parekh AA, Smith WR, Silva S, Agudelo JF, Williams AE, Hak D, et al. Treatment of distal femur and proximal tibia fractures with external fixation followed by planned conversion to internal fixation. J Trauma. 2008;64(3):736–9. doi:10.1097/TA.0b013e31804d492b.PubMedCrossRef

50.

Hontzsch D, Weller S, Engels C, Kaiserauer S. Change in the procedure from external fixator to intramedullary nailing osteosynthesis of the femur and tibia. Aktuelle Traumatologie. 1993;23(Suppl 1):21–35.PubMed

51.

Marshall PD, Saleh M, Douglas DL. Risk of deep infection with intramedullary nailing following the use of external fixators. J R Coll Surg Edinb. 1991;36(4):268–71.PubMed

52.

Maurer DJ, Merkow RL, Gustilo RB. Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation. J Bone Joint Surg Am. 1989;71(6):835–8.PubMed

53.

Sigurdsen U, Reikeras O, Utvag SE. The Effect of timing of conversion from external fixation to secondary intramedullary nailing in experimental tibial fractures. J Orthop Res. 2011;29(1):126–30. doi:10.1002/jor.21182.PubMedCrossRef

54.

Yokoyama K, Uchino M, Nakamura K, Ohtsuka H, Suzuki T, Boku T, et al. Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures. Injury. 2006;37(6):554–60. doi:10.1016/j.injury.2005.08.026.PubMedCrossRef

55.

Yokoyama K, Itoman M, Uchino M, Fukushima K, Nitta H, Kojima Y. Immediate versus delayed intramedullary nailing for open fractures of the tibial shaft: a multivariate analysis of factors affecting deep infection and fracture healing. Indian J Orthop. 2008;42(4):410–9. doi:10.4103/0019-5413.43385.PubMedCentralPubMedCrossRef

56.

Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma. 2005;19(7):448–55 (discussion 56).

57.

Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma. 1999;13(2):85–91.PubMedCrossRef

58.

Mauffrey C, Bailey JR, Bowles RJ, Price C, Hasson D, Hak DJ, et al. Acute management of open fractures: proposal of a new multidisciplinary algorithm. Orthopedics. 2012;35(10):877–81. doi:10.3928/01477447-20120919-08.PubMedCrossRef

59.

Wild M, Gehrmann S, Jungbluth P, Hakimi M, Thelen S, Betsch M, et al. Treatment strategies for intramedullary nailing of femoral shaft fractures. Orthopedics. 2010;33(10):726. doi:10.3928/01477447-20100826-15.PubMed

60.

Yokoyama K, Itoman M, Shindo M, Kai H, Ueta S, Kobayashi A. Deep infection and fracture healing in immediate and delayed locked intramedullary nailing for open femoral fractures. Orthopedics. 1999;22(5):485–90.PubMed

61.

Pape HC. Effects of changing strategies of fracture fixation on immunologic changes and systemic complications after multiple trauma: damage control orthopedic surgery. J Orthop Res. 2008;26(11):1478–84. doi:10.1002/jor.20697.PubMedCrossRef

62.

Winkler H, Hochstein P, Pfrengle S, Wentzensen A. Change in procedure to reamed intramedullary nail in diaphyseal femoral fractures after stabilization with external fixator. Zentralbl Chir. 1998;123(11):1239–46.PubMed

63.

Kazakos KJ, Verettas DJ, Tilkeridis K, Galanis VG, Xarchas KC, Dimitrakopoulou A. External fixation of femoral fractures in multiply injured intensive care unit patients. Acta Orthop Belg. 2006;72(1):39–43.PubMed

64.

Van den Bossche MR, Broos PL, Rommens PM. Open fractures of the femoral shaft, treated with osteosynthesis or temporary external fixation. Injury. 1995;26(5):323–5.PubMedCrossRef

65.

Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma. 2000;48(4):613–21 (discussion 21–3).

66.

Brundage SI, McGhan R, Jurkovich GJ, Mack CD, Maier RV. Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. J Trauma. 2002;52(2):299–307.PubMedCrossRef

67.

Taeger G, Ruchholtz S, Zettl R, Waydhas C, Nast-Kolb D. Primary external fixation with consecutive procedural modification in polytrauma. Der Unfallchirurg. 2002;105(4):315–21.PubMedCrossRef

68.

Giannoudis PV. Surgical priorities in damage control in polytrauma. J Bone Joint Surg Br. 2003;85(4):478–83.PubMedCrossRef

69.

Pape HC, Hildebrand F, Pertschy S, Zelle B, Garapati R, Grimme K, et al. Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J Trauma. 2002;53(3):452–61. doi:10.1097/01.TA.0000025660.37314.0F (discussion 61–2).

70.

Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246(3):491–9. doi:10.1097/SLA.0b013e3181485750 (discussion 9–501).

71.

Taeger G, Ruchholtz S, Waydhas C, Lewan U, Schmidt B, Nast-Kolb D. Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe. J Trauma. 2005;59(2):409–16 (discussion 17).

72.

Tuttle MS, Smith WR, Williams AE, Agudelo JF, Hartshorn CJ, Moore EE, et al. Safety and efficacy of damage control external fixation versus early definitive stabilization for femoral shaft fractures in the multiple-injured patient. J Trauma. 2009;67(3):602–5. doi:10.1097/TA.0b013e3181aa21c0.PubMedCrossRef

73.

Harwood PJ, Giannoudis PV, Probst C, Krettek C, Pape HC. The risk of local infective complications after damage control procedures for femoral shaft fracture. J Orthop Trauma. 2006;20(3):181–9.PubMed

Titel: Intramedullary nailing after external fixation of the femur and tibia: a review of advantages and limits
verfasst von: P. Pairon
C. Ossendorf
S. Kuhn
A. Hofmann
P. M. Rommens
Publikationsdatum: 01.02.2015
Verlag: Springer Berlin Heidelberg
Erschienen in: European Journal of Trauma and Emergency Surgery / Ausgabe 1/2015
Print ISSN: 1863-9933
Elektronische ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-014-0448-x

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