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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 96-99

Locked intramedullary nailing for tibial and femoral shaft fractures: Challenges and prospects in a Tertiary Health Care Facility in a resource constraint setting


Department of Orthopedics and Trauma Surgery, Ahmadu Bello University, Zaria, Nigeria

Date of Web Publication30-Nov-2016

Correspondence Address:
Ismail L Dahiru
Department of Orthopedics and Trauma Surgery, Ahmadu Bello University, Zaria
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.194982

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  Abstract 

Background: Locked intramedullary nailing for operative fixation of tibial and femoral shaft fractures has become the gold standard in the operative stabilization of these fractures. The results of these procedures from various centers have been quiet impressive and compares to that reported globally. The sustenance of these important procedures are however not without challenges, which is the main reason for reporting the experience from our institution.
Patients and Methods: This is a prospective study involving 163 consecutive patients with closed tibial and femoral shaft fractures over a period of two years (June 2011 to May 2013). Parameters such as blood loss, postoperative wound infection, length of hospital stay, and fracture union were followed up.
Results: One hundred and fifteen (70.6%) of the patients were males while 48 (29.4%) were females. Of the 176 operations, 136 (77.3%) were carried out for femoral shaft fractures whereas 40 (22.7%) were carried out for tibial shaft fractures. Thirty eight (21.6%) femurs and 14 (7.9%) tibiae had locked intramedullary nailing. Intraoperative blood loss was less than 250 ml in patients who had locked intramedullary nailing, and the average length of hospital stay was 10 and 16 days for those that had locked intramedullary nailing and plating, respectively. Forty-four (84.2%) fractures stabilized with locked intramedullary nail showing solid union at 16 weeks whereas only 32 (70%) and 55 (70%) of the fractures stabilized with Kuntscher nail and plate, respectively, showing solid union at 16 weeks.
Conclusion: Our study suggests satisfactory outcome with locked intramedullary nailing for the operative fixation of tibial and femoral shaft fractures. The choice of implant to be used depends significantly on affordability by patients and to a lesser extent on surgeon's preference.

Keywords: Femoral fractures, intramedullary nailing, tibial fractures, union


How to cite this article:
Dahiru IL, Amaefule KE, Lawal YZ, Ogirima M O, Maitama MI, Ejagwulu F, Abdulmalik MA. Locked intramedullary nailing for tibial and femoral shaft fractures: Challenges and prospects in a Tertiary Health Care Facility in a resource constraint setting. Arch Int Surg 2016;6:96-9

How to cite this URL:
Dahiru IL, Amaefule KE, Lawal YZ, Ogirima M O, Maitama MI, Ejagwulu F, Abdulmalik MA. Locked intramedullary nailing for tibial and femoral shaft fractures: Challenges and prospects in a Tertiary Health Care Facility in a resource constraint setting. Arch Int Surg [serial online] 2016 [cited 2021 Jan 16];6:96-9. Available from: https://www.archintsurg.org/text.asp?2016/6/2/96/194982


  Introduction Top


Locked intramedullary nailing for the operative stabilization of femoral and tibial shaft fractures has become the gold standard in the management of these fractures.[1],[2],[3] The recognition of absolute respect for soft tissues in the operative management of fractures to achieve biological fixation heralded the era of locked intramedullary nailing.[4] Locked intramedullary nailing is usually achieved via closed reduction of fracture and stabilization by insertion of intramedullary nails followed by proximal and distal locking under image intensification.[5],[6] Sometimes fracture reduction may require minimal opening.[7],[8] Other less desirable methods of operative stabilization of these fractures include the use of unlocked intramedullary nails and plates.[9],[10] The use of locked intramedullary nails has advantages in that it is associated with higher fracture union rates in over 97% of the cases.[11],[12],[13] It results in lower tensile and shear stresses on the implant than plate fixation, lower infection rates, and less extensive exposure and dissection during insertion.[14],[15] Locked intramedullary nailing has the advantage of preserving periosteal blood supply and controls alignment, translation, and rotation after fracture stabilization.[16],[17] Locking of the nail allows for restoration of length and early functional use of the extremity, thereby reducing the length of hospital stay and facilitating early return to work.[16],[17],[18] Plate fixation for the operative management of tibial and femoral shaft fractures is less desirable. It is associated with additional soft tissue injury during exposure, reduced vascularity beneath the plate, increased blood loss, stress shielding of the bone, and increased risk of infection.[19],[20]

Locked intramedullary nailing for the operative fixation of tibial and femoral shaft fractures has become generally acceptable in the management of these fractures in Nigeria. The last decade has witnessed considerable development with regard to this procedure and the availability of both instrumentation and implants in various centers. The results of these procedures from various centers have been quiet impressive and compares to that obtained globally.[1],[2],[3],[4] The sustenance of these important procedures are, however, not without challenges which is the main reason for reporting the experience from our hospital.


  Patients and Methods Top


This is a prospective study involving 163 consecutive patients with closed tibial and femoral shaft fractures over a period of two years (June 2011 to May 2013), during which 176 fractures where operated upon. All patients were scheduled to have locked intramedullary nailing of fractures except those that were adjudged unsuitable. The locked intramedullary nailing systems used for the stabilization of the fractures were Russel Taylor, Pitkar, and Nebular systems. The alternate systems used were the conventional Kuntscher nailing and dynamic compression plate fixation. Antegrade closed intramedullary nailing, and in some cases with minimal opening at the fracture site to achieve reduction, were used. The medullary canals were reamed in all the cases and two screws were inserted to achieve proximal and distal locking in those stabilized with locked intramedullary nail. Parameters with regard to intraoperative blood loss, postoperative wound infection, length of hospital stay, and fracture union were followed up.


  Results Top


One hundred and sixty-three patients with femoral and tibial shaft fractures were operated upon during the study period [Figure 1]a and [Figure 1]b. One hundred and fifteen (70.6%) of the patients were males whereas 48 (29.4%) were females. Seventy-five (45.4%) of the patients were within the age group of 16–30 years followed by the age group of 31–45 years, accounting for 48 (29.4%) of the total patients. Of the 176 operations, 136 (77.3%) were carried out for femoral shaft fractures whereas 40 (22.7%) were carried out for tibial shaft fractures [Figure 2]. Thirty-eight (21.6%) femurs and 14 (7.9%) tibias had locked intramedullary nailing. Fifty-three (30.1%) femur had intramedullary nailing with Kuntscher nail, 45 (21.6%) femurs had plating with broad dynamic compression plate (DCP) and 26 (14.8%) tibias had plating with narrow DCP [Figure 3]. Intraoperative blood loss was less than 250 ml in patients who had locked intramedullary nailing, and the average length of hospital stay was 10 and 16 days for those who had locked intramedullary nailing and plating, respectively. Only 2 (4.4%) of the patients who had Kuntscher nailing and 3 (3.8%) of the patients who had plating developed superficial wound infection, whereas no wound infection was recorded among patients who had locked intramedullary nailing. Partial weight bearing was commenced on the 5th postoperative day in patients who had locked intramedullary nailing. Forty-four (84.2%) fractures stabilized with locked intramedullary nail showing solid union at 16 weeks, whereas 32 (70%) and 55 (70%) of the fractures stabilized with Kuntscher nail and plate, respectively, showed solid union at 16 weeks [Figure 4]. Alternate use of implant in 80 (64.5%) fractures was due to financial constraint on the part of the patients, whereas it was surgeon's choice in 44 (35.5%).
Figure 1: Locked intramedullary nailing of (a) femoral shaft and (b) tibial shaft

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Figure 2: Distribution of femoral and tibial shaft fractures

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Figure 3: Distribution of technique of operative intervention for femoral shaft fractures

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Figure 4: Distribution of fracture union at 16 weeks

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  Discussion Top


The number of femoral shaft fractures managed operatively by intramedullary nailing far outnumber those carried out for tibial shaft fractures, as noted in our series. Similar studies have reported the same pattern with up to 50% of tibial fractures being managed conservatively with good results.[21],[22],[23] Very young adults were found to be commonly affected by these fractures as they occur following high energy injuries such as motor vehicular accidents. The predisposition of this particular age range correlates with their activity level and lifestyle. Although union rates of over 95% have been reported following intramedullary nailing, our series reported a slightly lower union rate of 84.2%.[11],[12],[13] This may be associated with assessment time. In most of the reported series, the time to union were assessed at between 20 weeks to 25 weeks.[11],[12],[13] In our series the union rates were assessed at 16 weeks. Our series also substantiated the benefit of locked intramedullary nailing with regards to reduced blood loss, good union rates, reduced length of hospital stay, reduced infection rate, and early ambulation.[16] The use of alternate implant was found to be quite high, with 64.5% of the reasons being financial constraints. Poverty and financial constraints have been found to be a major impediment in accessing qualitative health care.[24] This has led to agitations for universal health coverage which is aimed at giving every one the health care services they need without causing financial hardship. The 25 wealthiest nations except United States and several middle income countries such as Brazil, Mexico, and Thailand all have some form of universal health coverage.[24] The Nigerian National Health insurance Scheme (NHIS) is designed to attract more resources to the health care sector and improve access and utilization of health care services.[25] It is also expected to protect people from the catastrophic financial implications of illness.[25] The NIHS, therefore, represents a very promising sustainable health care financing strategy.[26] At present, the NHIS is limited to the formal sector and is also limited in the scope of health care services covered; implants and other orthopedic consumables are inclusive. The agency can work progressively toward achieving universal health coverage for all Nigerians. There is, therefore, a strong need to further strengthen the NHIS to enable Nigerians access qualitative health care services at an affordable cost.


  Conclusion Top


Locked intramedullary nailing for tibial and femoral shaft fractures still remains the gold standard. Our study suggests satisfactory outcome with locked intramedullary nailing for operative fixation of tibial and femoral shaft fractures. The choice of the implant to be used, however, depends significantly on affordability by the patients and to a lesser extent on surgeon's preference. To offer patients the ideal implant during fracture stabilization, there is a need to improve the scope of the coverage of the NIHS by extending it to the informal sector.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ricci WM, Gallagher B, Haidukewych GJ. Intramedullary nailing of femoral shaft fractures: Current concepts. J Am Acad Orthop Surg 2009;17:296-305.  Back to cited text no. 1
    
2.
Duan X, Al-Qwbani M, Zeng Y, Zhang W, Xiang Z. Intramedullary nailing for tibial shaft fractures in adults. Cochrane Database Syst Rev 2012;1:CD008241.  Back to cited text no. 2
    
3.
Amupitan I, Michael OB, Onche II. Management of tibial shaft fractures using Unreamed Locked Intramedullary Nails: Our Experience from Jos, North Central Nigeria. IOSR-JDMS 2015;14:33-6.  Back to cited text no. 3
    
4.
Ansorge D, Hinze M. Interlocking nailing; indication and technique. Zentralblatt fur chirurgie. Zentralbl Chir 1977;102:394-403.  Back to cited text no. 4
    
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Bong MR, Kummer FJ, Koval KJ, Egol KA. Intramedullary nailing of the lower extremity: Biomechanics and biology. J Am Acad Orthop Surg 2007;15:97-106.  Back to cited text no. 5
    
6.
Bhandari M1, Guyatt GH, TornettaP3rd, Swiontkowski MF, Hanson B, Sprague S, et al. Current practice in the intramedullary nailing of tibial shaft fractures: An international survey. J Trauma 2002;53:725-32.  Back to cited text no. 6
    
7.
Alho A, Ekeland A, Strømsøe K, Benterud JG. Nonunion of tibial shaft fractures treated with locked intramedullary nailing without bone grafting. J Trauma 1993;34:62-7.  Back to cited text no. 7
    
8.
Grantham SA, Craig M. Open intramedullary nailing of the femoral shaft fracture. Orthop Rev 1986;15:426-32.  Back to cited text no. 8
    
9.
Hansen ST, Winquist RA. Closed intramedullary nailing of the femur. Kuntscher technique with reaming. Clin Orthop Relat Res 1979;138:56-61.  Back to cited text no. 9
    
10.
Bombaci H1, Güneri B, Görgeç M, Kafadar A. A comparison between locked intramedullary nailing and plate-screw fixation in the treatment of tibal diaphysis fractures. Acta Orthop Traumatol Turc 2004;38:104-9.  Back to cited text no. 10
    
11.
Winquist RA, Hansen ST Jr, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. J bone Joint Surg Am 1984;66:529-39.  Back to cited text no. 11
    
12.
Follerås G1, Ahlo A, Strømsøe K, Ekeland E, Thoresen BO. Locked intramedullary nailing of fractures of femur and tibia. Injury 1990;21:385-8.  Back to cited text no. 12
    
13.
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;70:1453-62.  Back to cited text no. 13
    
14.
Strecker W, Suger G, Kinzl L. Local complications of intramedullary nailing. Orthopade 1996;25:274-91.  Back to cited text no. 14
    
15.
Baixauli F Sr, Baixauli EJ, Sánchez-Alepuz E, Baixauli F Jr. Interlocked intramedullary nailing for treatment of open femoral shaft fractures. Clin Orthop Relat Res 1998;350:67-73.  Back to cited text no. 15
    
16.
Timmerman LA, Rab GT. Intramedullary nailing of femoral shaft fractures in adolescents. J Orthop Trauma 1993;7:331-7.  Back to cited text no. 16
    
17.
Court-Brown CM, Keating JF, McQueen MM. Infection after intramedullary nailing of the tibia. Incidence and protocol for management. J Bone Joint Surg Br 1992;74:770-4.  Back to cited text no. 17
    
18.
Deepak MK, Jain K, Rajamanya KA, Gandhi PR, Rupakumar CS, Ravishankar R. Functional outcome of diaphyseal fractures of femur managed by closed intramedullary interlocking nailing in adults. Ann Afri Med 2012;11:52-7.  Back to cited text no. 18
    
19.
Ruedi TP, Murphy WM. AO Principles of Fracture Management. ???: Thieme Publishing Group; 2000. p. 195-220.  Back to cited text no. 19
    
20.
Huang P, Tang PF, Yao Q, Liang YT, Tao S, Zhang Q, et al. A comparative study between intramedullary nailing and plate-screw fixation in the treatment of tibial shaft fractures. Zhongguo Gu Shang 2008;21:261-3.  Back to cited text no. 20
    
21.
Toivanen JA. The management of closed tibial shaft fractures. Current Orthopaedics 2003;17:167-75.  Back to cited text no. 21
    
22.
Lindsey RW, Blair SR. Closed tibial shaft fractures: Which ones benefit from surgical treatment? J Am Acad Orthop Surg 1996;4:35-43.  Back to cited text no. 22
    
23.
Hooper GJ, Keddell RG, Penny ID. Conservative management or closed nailing for tibial shaft fractures. A randomized prospective trial. J Bone Joint Surg Br 1991;73:83-5.  Back to cited text no. 23
    
24.
Rodin J, de Ferranti D. Universal health coverage: The third global health transition? Lancet 2012;380:861-2.  Back to cited text no. 24
    
25.
Onwujekwe OE, Uzochukwu BS, Ezeoke OP, Uguru NP. Health insurance: Principles, models and the Nigerian National Health Insurance Scheme. IJMHDEV 2011;16:45-56.  Back to cited text no. 25
    
26.
Obalum DC, Fiberesima F. Nigerian National Health Insurance Scheme (NHIS): An overview. Niger Postgrad Med J 2012;19:167-74.  Back to cited text no. 26
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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