The study included 51 patients with tibia fractures, who underwent percutaneous bone reposition and stabilization
with unrimed tibial locking nail. The results obtained using this method were compared with those obtained by standard
fracture treatment where flat and anatomic plates were applied (n=64). In patients who had osteosynthetic material implanted
percutaneously (using unrimed tibial locking nail) there was no incidence of post surgical osteitis or any pseudarthrosis.
The healing callus of the fracture was of lesser quality and spindle shaped, suggesting that fracture stabilization
using this method was less efficient. In patients with fractures stabilized by the open method using flat and anatomic
plates (n=64), we noticed 3.1% (n=2) cases of osteitis and 4.7% (n=3) cases of pseudarthrosis. Due to lesser incidence
of postoperative osteitis, our method of choice in tibia fractures would be percutaneous stabilization with unrimed
tibial locking nail. However, this treatment method has its disadvantages, too. Fracture callus is of lesser quality and it
is spindle shaped. Furthermore, there are problems with adequate percutaneous reposition in some cases, as well as necessity
for radiological checking

Borislav Has

Igor Lekšan

Ivan Lovrić

Milan Rukavina

Radivoje Radić

Savo Jovanović

Saša Rapan

English

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Coll. Antropol. 31 (2007) 4: 1015–1018Original scientific paperThe Analysis of the Unstable Tibia FractureTreatment Applying Internal Stabilization MethodIvan Lovri}1, Borislav Has1, Savo Jovanovi}², Igor Lek{an1, Radivoje Radi}³, Sa{a Rapan2and Milan Rukavina11 Department of Surgery, University Hospital »Osijek«, Osijek, Croatia,² Department of Orthopaedics, University Hospital »Osijek«, Osijek, Croatia,³ Department of Anatomy, School of Medicine, University »J.J. Strossmayer«, Osijek, CroatiaA B S T R A C TThe study included 51 patients with tibia fractures, who underwent percutaneous bone reposition and stabilizationwith unrimed tibial locking nail. The results obtained using this method were compared with those obtained by standardfracture treatment where flat and anatomic plates were applied (n=64). In patients who had osteosynthetic material im-planted percutaneously (using unrimed tibial locking nail) there was no incidence of post surgical osteitis or any pseu-darthrosis. The healing callus of the fracture was of lesser quality and spindle shaped, suggesting that fracture stabiliza-tion using this method was less efficient. In patients with fractures stabilized by the open method using flat and anato-mic plates (n=64), we noticed 3.1% (n=2) cases of osteitis and 4.7% (n=3) cases of pseudarthrosis. Due to lesser inci-dence of postoperative osteitis, our method of choice in tibia fractures would be percutaneous stabilization with unrimedtibial locking nail. However, this treatment method has its disadvantages, too. Fracture callus is of lesser quality and itis spindle shaped. Furthermore, there are problems with adequate percutaneous reposition in some cases, as well as ne-cessity for radiological checking.Key words: fractures tibiae, tibial nail, plate, osteitisIntroductionThe inner stabilization is most frequently used intreatment of unstable closed and open lower-extremitylong bone fractures1. In order to stabilize these fractureswell, most frequently flat and round anatomic plates areused, as well as Kuntscher nails. The principal conditionin successful inner stabilization of the fracture is the ab-sence of injured limb infection. The incidence of osteitisand pseudarthrosis seems to be higher in tibia fracturesthan in thigh or upper extremity fractures. These com-plications represent a big medical and economical prob-lem and affect the functional status of the extremities.The treatment of unstable fractures of hand and footshort bones with the low-profile mini-plating system cancause the formation of scars and contractions of the func-tionally important joints2. The minimum osteosynthesisof the short bones with Kirschner wires is accompaniedby a minor surgical trauma and satisfactory functionalresults3,4.The external fixation is a method of choice in stabili-zation of unstable long bone fractures of the second andthird degree5, often with massive joint and soft tissueinjuries6,7. The incidence of postoperative complicationsin long bone fractures of the lower extremities sustainedin the war is higher than in peacetime fractures5,8.In recent years we have stabilized closed or open tibiafractures of the first degree in our patients by intrame-dullary unrimed tibia-locking nail. The osteosyntheticmaterial has been implanted percutaneously and intra-medullary using the appropriate technological equip-ment and then radiologically checked.The study describes our clinical experiences and ob-servations regarding the treatment of war and peacetimefractures of the same localization by external fixationand internal stabilization.Furthermore, both advantages and disatvantages arepresented, including some less popular factors in treat-1015Received for publication November 8, 2007ment of tibia fractures using percutaneous intemedullarstabilization method with unrimed tibial locking nail.Patients and MethodsTwo groups of patients with unstable tibia fractureswere compared. In the first group, the fracture stabiliza-tion was performed by a standard open method using flatand anatomical plates. In the second group, the fracturesof the same localization were stabilized percutaneouslyand intramedullary with unrimed tibial locking nail andthen radiologically checked.The first group consisted of patients with unstableclosed and open tibia fractures of the first degree thatwere treated by customary techniques and methods inthe last two years. The fracture stabilization was pre-formed after standard surgical incision in the fracturearea and open reposition.The surgery was performed immediately after hospi-talization and preoperative and anaesthesiological prep-arations. In preoperative treatment some patients re-ceived antibiotics (Vancomycin, Ceftazidin or Mero-penem). The indications and the antibiotic choice weredetermined by the surgical team.In the choice of antibiotics, we followed our depart-ment’s clinical experience regarding the most pathogenicmicrobial flora: Staphylococcus aureus and epidermis,Pseudomonas aeruginosa, Serratia, Klebsiella and Pro-teus mirabilis.Osteosynthesis material was chosen according to frac-ture site. Anatomical plates were used in tibia fracturesin the upper or lower third, whereas in other fracturesites flat plates were used. The patients with the fracturewithin the joint (knee or ankle) were not included in thestudy. We tried to form groups of patients with the sameor similar fractures and then apply different method intheir treatment. The group treated by internal osteosyn-thesis of tibia (with flat and anatomic plates) consisted of64 patients. All patients were postoperatively treated byanti thrombus medications and walking therapy using astick or walker. Majority of patients with only tibia frac-tures could walk on their own very soon.After patients’ release from hospital, follow up in-cluded regular radiological checking to monitor the re-covery and to advise patients on how to proceed with thetibial loading. There was no significant difference be-tween these two patient groups in the recovery speed.The patients were followed for one more year and therewere no significant differences in the functional status oflower leg fractures treated either with unrimed tibial in-terlocking nail or with plates.The incidence of complications, including pseudar-throsis and osteitis is described in the results.The second group consisted of 51 patients with unsta-ble closed and open tibia fractures of the first degree. Thefracture stabilization in this group was performed usingpercutaneous unrimed tibial locking nail (Figure 2). Infirst degree open fractures the wound was surgicallytreated, followed by reposition and radiological checking.If the percutaneous reposition failed and there was inad-missibly large space between the bone fragments wechanged the treatment method. These patients under-went a small incision of soft tissue in the fracture areaand visually controlled reposition. The bone stabilizationwas performed using a plate or unrimed tibial lockingnail. These patients were not included in the group 2.The site where the nail was inserted was typical, justabove the tuberositas tibiae9. In order to find the exactsite for bone trepanation we used radiography, whereasthe length and the size of the tibial nail were determinedaccording to standard procedure10,11.The fracture reposition, the insertion of the tibial nailand its fixation required appropriate equipment, trau-matological experience and radiological checking.Patients treated in this way were allowed to load theoperated tibia freely very soon after the surgery. Thiswas of great importance and benefit to the elderly pa-tients who find it hard to use their orthopedic aids. Thefollow up period for our patients was one year. Duringthis period we could observe bigger (spindle shaped) cal-lus at the site of the bone fracture, suggesting that thefracture stabilization with unrimed tibial locking nailwas not the best method of choice. Yet, in these patientsthere was no pseudarthrosis or osteitis.ResultsIn table 1 it is evident that 95.31% (n=61) of thegroup 1 patients had closed tibia fractures, while 4.69%(n=3) had open fracture of the first degree. No injuries toimportant blood vessels were detected.I. Lovri} et al.: Treatment Methods of Tibia Fractures, Coll. Antropol. 31 (2007) 4: 1015–10181016TABLE 1NUMBER OF CLOSED AND OPEN TIBIA FRACTURES OF THE FIRST DEGREE TREATED WITH FLAT AND ANATOMICAL PLATES(GROUP 1) OR UNRIMED TIBIAL LOCKING NAIL (GROUP 2) AND COMPLICATION INCIDENCESurgicalmethod(stabilization)Fracture type ComplicationsClosedN (%)Open 1stdegree N (%)TotalN (%)Injury to bigblood vesselsN (%)OsteitisN (%)PseudarthrosisN (%)Group 1 Internal 61 (95.31%) 3 (4.69%) 64 (100.00%) 0 (0%) 2 (3.13%) 3 (4.69%)Group 2 Intramedullar 34 (66.67%) 17 (33.33%) 51 (100.00%) 0 (0%) 0 (0%) 0 (0%)Two patients (3.13%) had osteitis and in 3 patients(4.69%) the fracture did not heal due to pseudarthrosis.In group 2, 66.67% (n=34) of patients had closed frac-tures and 33.33% (n=17) had open fractures of the firstdegree. There were no injuries to important blood vesselsand no cases of osteitis or pseudarthrosis.Table 2 shows indication for the fracture stabilizationin group 1. Anatomical plates were mostly indicated intibia fracture of the lower third part (n=32, 50.00%). Ma-jority of these fractures were diagonal and spiral.In group 2 indication for unrimed tibial locking nailwas the tibia fracture of the medium part (n=26, 50.98%).The fractures were mostly vertical or crenated, and rare-ly diagonal or spiral.DiscussionTibia fractures occur rather frequently in trauma-tological surgery, especially unstable tibia fractures.Most frequent treatment method in unstable tibia frac-tures of the first degree is surgical stabilization with flatand anatomical plates1. The method consists of incisionof soft tissue in the fracture area, revision and visualfracture reposition and the stabilization with appropri-ate osteosynthetic material. Possible complications ofsurgical treatment and wound contamination in openfractures are osteitis and pseudarthrosis. In group 1,where fracture stabilization was performed using flatand anatomical plates there were 3.13% (n=2) cases ofosteitis in post surgical period and 4.69% (n=3) cases ofpseudarthrosis (Table 1 and 2). The incidence of thesecomplications is significant, but acceptable since similaror even higher incidence is mentioned by some otherauthors11–13. Tibia fracture stabilization with anatomicalplates was performed mostly in spiral and diagonal frac-tures of the lower third (Table 2, n=32,50%). The out-growing quality of the fracture and the shape of callusare shown in Figure 1a and b.In the last two years, besides the mentioned methodof internal stabilization with the plates, we have startedwith the tibial fracture stabilization using unrimed tibiallocking nail. In group 2 we had no cases of osteitis andpseudarthrosis in the follow up period (Table 1 and 2)and the fracture healed creating spindle shaped callus(Figure 2a and b). Most fractures treated with this me-thod occurred on the medium part of tibia (Table 2,n=26,51%).The spindle shaped callus suggests that fracturetreatment with unrimed tibial locking nail is of lesserstabilization quality. We prefer percutaneous fractureI. Lovri} et al.: Treatment Methods of Tibia Fractures, Coll. Antropol. 31 (2007) 4: 1015–10181017TABLE 2TIBIA FRACTURE SITE IN PATIENTS TREATED WITH THE FLAT AND ANATOMICAL PLATES (GROUP1) AND IN PATIENTS WITH THESAME FRACTURE TYPE TREATED WITH INTRAMEDULLAR STABILIZATION (GROUP 2)Surgical method(stabilization)Fracture siteTotalN (%)Upper thirdN (%)Medium thirdN (%)Lower thirdN (%)Group 1 Internal 9 (14.06%) 23 (35.94%) 32 (50.00%) 64 (100.00%)Group 2 Intramedullar 6 (11.76%) 26 (50.98%) 19 (37.25%) 51 (100.00%)Fig 2. a) stabilization of tibia fracture with the unrimed tibiallocking nail, b) spindle shaped callus after the fracture treatmentand removal of osteosynthesis material.Fig 1. a) stabilization of the tibia fracture with anatomical plate,b) callus shape after the fracture treatment and removal ofalenthesis.stabilization with intramedullar tibial nail due to lesserincidence of postoperative osteitis in comparison to thestandard open method and visual fracture reposition.This method is extremely efficient in vertical and crena-ted fractures of the medium third part of the tibia, sincethe percutaneous fracture reposition with radiologicalchecking is done routinely.We would like to point out that there are some diffi-culties in percutaneous fracture reposition, especially inpreserving continuity of calf bone and in spiral fracturesor if there are small fragments in the fracture hole. Inthe absence of anatomical fracture repositioning and lessadequate positioning of unrimed tibial locking nail, thefracture would be less stable and spindle shaped calluswould be of lesser quality. The treatment method byunrimed tibial locking nail is not very popular amongsurgeons because the reposition is not always successful,lasts long because of radiological checking and it requiresgood training. Therefore we have used unrimed tibiallocking nail in patients in group 2 only where percuta-neous fracture reposition was successful.The problem with long lasting radiological checkingand difficult repositioning could be partially solved bysmaller incision and minor injury to the soft tissue at thefracture site and visually controlled repositioning.Our clinical experience from the war period showsthat the incidence of complications in treatment of longextremity bones, such as osteitis and pseudarthrosis(8.3% and 3.7% respectively) is much higher. We can con-clude that the incidence of complications after surgerydepends on wound contamination in open fractures aswell as on trauma severity5,14,15. The results of this studyshow that postoperative complications, like osteitis, alsodepend on selection of surgical treatment method.R E F E R E N C E S1. MÜLLER ME, ALLGOEWER M, WILLENEGGER H, Manual ofInternal Fixation (Springer-Verlag, Berlin, Heidelberg, New York, Tokyo,1991). — 2. O’SULLIVAN ST, LIMANTZAKIS G, KAY SP, J Hand Surg,24(1999) 347. — 3. MANNER M, ROESLER B, Chirurg, 71 (2000) 326. —4. HAS B, JOVANOVI] S, WERTHEIMER B, KOND@A G, GRDI] P, LE-KO K, Croat Med J, 42 (2001) 630. — 5. HAS B, JOVANOVI] S, WER-THEIMER B, MIKOLA[EVI] B, GRDI] P, Injury, 26 (1995) 245. — 6.SALAMON A, SALAMON T, NIKOLIC V, RADIC R, NIKOLIC T, JO-OS-VATIC A, Coll Antropol, 27 (2003) 645. — 7. RADIC R, NIKOLIC V, KAR-NER I, KURBEL S, SELTHOFER R, Coll Antropol, 26 Suppl (2002) 59.— 8. HAY SM, RICKMAN M, SALEK M, Injury, 28 (1997) 437. — 9.GOESSENS MLMJ, SIJEBERS R, HARBERS JS, STAPERT JWJL, Os-teosinthese International, 9 (2001) 101. — 10. HUTSON JJ, ZYCH GA,COLE JD, JOHNSON KD, OSTERMANN P, MILNE EL, LATTA L, ClinOrthop, 315 (1995) 129. — 11. GONOSCHOREK O, HOFMANN GO,BÜHREN V, Arch Orthop Trauma Surg, 117 (1998) 430. — 12. COLESCP, GROSS M, Canadian Journal of Surgery, 43 (2000) 256. — 13. PA-TZAKIS MJ, ZALAVRAS CG, Journal of the American Academy of Ortho-paedic Surgeons, 13 (2005) 417. — 14. TULNER AF, SCHAAP GR,STRACKEE SD, BESSELAAR PP, LUITSE JS, MARTI RK, Journal ofTrauma-Injury Infection and Critical Care, 56 (2004) 633. — 15. HAS B,NAGY A, PAVI] R, SPLAVSKI B, KRISTEK J, VIDOVI] D, Mil Med, 171(2006) 88.I. Lek{anDepartment of Anatomy, School of Medicine, University »J.J. Strossmayer«, J. Huttlera 4, 31000 Osijek, Croatiae-mail: igor_leksan@net.hrANALIZA NESTABILNIH LOMOVA GOLJENI^NE KOSTI METODOM UNUTARNJE STABILIZACIJES A @ E T A KAnalizirali smo 51 bolesnika s lomom goljeni~ne kosti, koji su bili podvrgnuti perkutanoj repoziciji i stabilizacijineboraju}im tibijalnim ~avlom. Rezultate lije~enja usporedili smo s ishodom standardnog lije~enja lomova kori{tenjemravnih i anatomskih plo~a na uzorku 64 bolesnika. U bolesnika lije~enih perkutanom metodom osteosinteze nisu zabi-lje`eni slu~ajevi osteitisa i pseudartroze. S druge strane, u bolesnika koji su lije~eni otvorenom metodom, uz kori{tenjeravnih i anatomskih plo~a (n=64), u 3.1% (n=2) bolesnika javio se osteitis i u 4,7% (n=3) pseudartroza. Zbog manjeincidencije osteitisa, na{a je metoda izbora u lije~enju lomova goljeni~ne kosti perkutana stabilizacija neboraju}im tibi-jalnim ~avlom. S druge strane, navedena metoda ima i nedostataka. Ko{tani kalus je slabije kvalitete i cilindri~nog jeoblika. Tako|er, ponekad nije mogu}a egzaktna repozicija i nu`no je intraoperacijsko radiolo{ko pra}enje.I. Lovri} et al.: Treatment Methods of Tibia Fractures, Coll. Antropol. 31 (2007) 4: 1015–10181018

The Analysis of the Unstable Tibia Fracture Treatment Applying Internal Stabilization Method

The Analysis of the Unstable Tibia Fracture Treatment Applying Internal Stabilization Method

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