SIGN interlock nailing in open fractures of tibia- Clinical Experience Dr. M. Saha1, Dr. S. Nandy2, Dr. D. Banerjee3 , Dr. A. K. Pa14 ,

Dr. C. Nath 5, Dr. A. N. Mukherjee6

Objectives:

Open fracture of tibia is one of the most common injuries seen in orthopaedic practice. Various modalities of treatment are practiced ranging from the age old treatment with plaster to debridement and surgical stabilization. Various modes of surgeries available, are external fixation, open reduction as, internal fixation (ORIF) with DCP after wound healing and primary unreamed interlocking nail External Fixator leads to an inherent morbidity, pin tract infection, malunion, nonunion etc. ORIF with DCP also has its associated complication. Pre debridement followed by unreamed interlocking nail provides a reliable alternative'. We used SIGN Interlocking nail for treatment of open tibial fractures which is advantageous because of its special design concept and it's unique locking mechanism. This study was done to see whether SIGN unreamed interlocking nail could provide a reliable option for treatment of open tibial fracture.

Materials and Methods:

A total of 21 patients were taken up for the study. Male-female ration was 9:12. There were 8 right sided and 13 left sided fractures. Out of 21, 3 cases involved fracture of upper third tibia, 5 middle third , 9 junction of middle and lower third and 4 lower third tibia respectively. Ten cases had Gustilo Type I injury and the remaining 11 Gustilo Type II. Three patients had fracture due to direct trauma and the remaining 18 due to RT N. 25% patients had other associated injuries. One patient had ipsilateral Malleolar fracture.

All patients were primarily resuscitated and evaluated for associated injuries. Routine wound swab was sent for Culture and Sensitivity test. Wound irrigation and primary debridement were done with gentle pulsatile lavage. In fraver our broad spectrum antibiotic with Injection Cefuroxine (1.5gm) and Injection Amikacin (500

1.& 2. Resident Surgeon, Dept. of Orthopaedics, J. N. Roy Hospital, Kolkata

3.& 4. Assistant Professor, Dept. of Orthopaedics, Burdwan Medical College, Burdwan

5. Assistant Professor, Dept. of Orthopaedics, Midnapore Medical College, Midnapore

6. Head of the Dept. Orthopaedics, J. N. Roy Hospital, Kolkata

Vol. 21, No.1, July 2006 39

mg) were used routinely. Eleven patients were operated within 24 hours and 10 patients were operated 5 to 7 days after injury. Patient was positioned .supine on t~e operation table . The site of entry of the nail was supenor to the medial half of tibial tuberosity. In 14 cases, a patellar tendon splitting approach was used, and entry to medial to patellar tendon in 7 cases. Appropriate sized sol id, unreamed SIGN nail was used in all cases. Closed reduction was achieved in all cases. Proximal and distal locking were done by unique SIGN locking mechanism (Fig. 1). Initially cases were done under C-Arm guidance. Later 8 cases, were done without C-Arm guidance. Primary suturing of wound was done in 15 cases, delayed primary suture in 5 and secondary skin grafting in 1 case. Operative time ranged between 45 to 90 minutes.

Fig :1

Post operatively, the limb was kept elevated on pillows. Parenteral Antibiotics were administere~ for 5 days followed by oral antibiotics til l removal of stitches. Quadriceps exercises were started after subsidence of pain. Active knee bending exercises were started after stitch removal (12 to 14 days). Partial weight bearing was allowed after the patient could perform active Straight leg raiSing (SLR) (avegare: 6 weeks). Full weight bearing was allowed after evidence of clinical and radiological union (average:14to 16weeks).

Observation and Results:

The duration of follow up ranged from 6 to 28 months averaging 20 months. All fractures united uneventfully except in one case (Gustilo type II) which showed delayed union. No significant difference was noted in the quality

of fracture union where operation was done within 24 hours or after 5 to 7 days of injury. Wound healed within two weeks, in all cases except in two patients who had superficial infection and deep infection. The initvally sent wound swab for culture sensitivity showed staphylococcus aurens in 8 patients, Ecoli 1 and no growth in 12 cases on day 1 or on admission 3 t07.

Cefuroxine and Amikacin proved effective antibiotic regimen in open fracture. Valgus malunion was seen in 1

Pre ,Per and Po't~, ClbW:al Photograp h & Radmgrap h

Fig :2

Fig :3

patient, limb shortening> 2 cm in 1 patient on 16 months follow up. All patients recovered almost full knee and ankle motions except in one patient who showed restriction of motions. Overall, clinico-radiological 95% satisfactory results were achieved by using unreamed SIGN nail fixation (Fig. 2, 3 & 4).

Discussion:

The study showed that solid unreamed SIGN nail maintained the cortical blood flow and provide stable fixation. The device reserved the soft tissue sleeve around the fracture side and allowed early motion of adjacent joints 8, The SIGN nailing procedure is simple, easy, fast and easily reproducible by an average orthopaedic surgeon. Other potential advantages include shorter operative time and less blood loss. Primary wound irrigation, debridement and soft tissue coverage was found to be very important in prevention of infection in Gustilo Type I and II injuries. As SIGN nail has an unique technique in locking mechanism, so this nail can also be used in peripheral centre, where C-Arm and other sophisticated equipments are not available.

Conclusion:

The treatment protocol using solid unreamed SIGN interlocking Nailing even without C-Arm guidance can be a suitable treatment option for open fractures of tibia.

References:

1) Keating JF , O'Brien PJ , Blachut PA, Meek RN, Broekhuyse HM : Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft : A prospective, randomized study. J Bone Joint Surg Am 1997;79:334-341.

2) Gustilo RB, Mendoza RM, Williams DM : Problems in the management of open fractures: J Trauma 1984; 24:742-746.

3) Johnson EE, Simpson LA, Helfet DL: Delayed intramedullary nailing after failed external fixation of the tibia, Clin Orthop 253:251, 1990.

4) Miller ME, Ada JR, Webb LX: Treatment of infected nonunion and delayed union of tibia fractures with locking intramedullary nails, Clin Orthop 245:233, 1989.

5) Templeman D, Thomas M, Varecka T, Kyle R: Exchange reamed intramedullary nailing for delayed union and nonunion of the tibia, Clin Orthop 315 : 169, 1995

6) Tornqvist H : Tibia nonunions treated by interlocking nailing : increased risk of infection after previous external fixation. J Orthop Trauma 4:109, 1990.

7) McQueen MM, Court-Brown CM: Compartment monitoring in tibial fractures: The pressure threshold for decompression. J Bone Joint Surg Br 1996;78:99-104.

8) Clatworthy MG, Clark DI, Gray DH, Hardy AE : Reamed versus unreamed femoral nails: A randomized,

Fig :4 prospective trial. J Bone Joint Surg Br 1998;80:485-489.

40 Journal of West Bengal Orthopaedic Association