Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. A comparison of one versus two distal locking screws in tibial fractures treated with unreamed tibial nails: a prospective randomized clinical trial. Comparison between ender and unreamed interlocking nails in tibial shaft fractures. Anterior knee pain after intramedullary nailing of fractures of the tibial shaft. A prospective, randomized study comparing two different nail-insertion techniques. Effect of acute reamed versus unreamed intramedullary nailing on compartment pressure when treating closed tibial shaft fractures: a randomized prospective study. Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years' follow-up. Treatment of unstable tibial fractures with interlocking nail versus Ender nail: a prospective evaluation.
One hundred and fifty-two patients who had 154 closed fractures of the shaft of the tibia were prospectively randomized to management with interlocking intramedullary nailing either with or without reaming. Thirteen patients who had been randomized to treatment without reaming were switched to the group that had reaming because of technical reasons; these patients were excluded from the analysis of the results. An additional five patients were lost to follow-up. Thus, seventy-two patients (seventy-three fractures) who had been managed with nailing with reaming and sixty-three patients (sixty-three fractures) who had been managed with nailing without reaming were available for follow-up at an average of twelve months (range, three to thirty-three months) postoperatively. The two groups were similar with regard to demographics and the configurations of the fractures. The average total duration of the procedures performed without reaming was eleven minutes shorter than that of the procedures done with reaming (p = 0.0013). The duration of fluoroscopy was not significantly different between the two groups (p = 0.35, Mann-Whitney test). The average estimated blood loss was identical for the two groups. Seventy fractures (96 per cent) that were treated with nailing with reaming and fifty-six (89 per cent) that were treated with nailing without reaming united without the need for an additional operation (p = 0.19). Because of the small sample size, the study has insufficient power (34.7 per cent) to detect this difference if it is real. There was only one deep infection, which developed after nailing without reaming. The nail fractured after one procedure with reaming. A screw fractured after two procedures with reaming and after ten without reaming (p = 0.012); multiple screws fractured after three procedures in the latter group. Malunion occurred after three nailing procedures with reaming and after two without reaming. Four malunions were of very proximal fractures and one was of a very distal fracture. Seventeen screws and twenty-four nails were removed after nailing with reaming, and twenty screws and nineteen nails were removed after nailing without reaming; neither of these prevalences was significantly different between the two groups (p = 0.27 and 0.89; chi-square test). We concluded that there are no major advantages to nailing without reaming as compared with nailing with reaming for the treatment of closed fractures of the shaft of the tibia. There was a higher prevalence of delayed union and breakage of screws after nailing without reaming. The objective was to determine whether the number of interlocking screws have an impact on hardware failure. In a clinical prospective randomized study of skeletally mature patients with diaphyseal tibial fractures, 44 were randomized pre-operatively into the two treatment arms over a two-year period. Two patients, one from each group, were excluded later. Of eligible patients, 22 had one distal locking screw and 20 had two distal locking screws. One distal screw failed (59.1 per cent) significantly more often than two distal screws (5 per cent). Screw failure occurred more often in heavier patients and usually between six and 12 weeks. Proximal screw failure was seen in 17 per cent of patients. There was no significant difference between groups with respect to fracture union. To compare ender nails and unreamed interlocking nails in a randomized clinical trial study.
                From March 2001 to March 2003, 131 patients with tibial fractures of the central two thirds of the tibia were admitted to the emergency ward of Shohada Hospital, Tabriz, Iran and were randomized to either an ender tibial nail or an undreamed interlocking tibial nail as their primary treatment. Age, gender, types of fracture, and surgical outcomes were recorded at the time of surgery, during hospital stay, and during the course of 9 months follow-up.
                Sixty-seven patients underwent surgery with interlocking nails and 64 with ender nails. No statistically significant difference was found between the 2 groups concerning mal-union, delayed union, and device failure. Durations of hospital stay, and time needed to achieve union was significantly higher in the unreamed interlocking group. Non-union and infection rate were higher in the ender group (p<0.05).
                The results of our study support those of other studies that indicate the choice between the 2 methods of unreamed nailing is mainly controversial, depending on the priorities of the patient and surgeon. Anterior knee pain is the most common complication after intramedullary nailing of the tibia. Dissection of the patellar tendon and its sheath during nailing is thought to be a contributing cause of chronic anterior knee pain. The purpose of this prospective, randomized study was to assess whether the prevalence or the intensity of anterior knee pain following intramedullary nailing of a tibial shaft fracture is reduced by the use of a paratendinous incision for the nail entry portal.
                Fifty patients with a tibial shaft fracture requiring intramedullary nailing were randomized equally to treatment with paratendinous or transtendinous nailing. Twenty-one patients from both study groups were followed for an average of three years after nailing. After fracture union, all but two patients had elective nail removal through the same surgical approach as was used for the nailing. At the follow-up evaluation, the patients used visual analog scales to report their level of anterior knee pain and the impairment caused by that pain. The scales described by Lysholm and Gillquist and by Tegner et al., the Iowa knee scoring system, and simple functional tests were used to quantitate the functional results. Isokinetic thigh-muscle strength was also measured.
                Fourteen (67%) of the twenty-one patients treated with transtendinous nailing reported anterior knee pain at the final evaluation. Of these fourteen patients, thirteen were mildly to severely impaired by the pain. Fifteen (71%) of the twenty-one patients treated with paratendinous nailing reported anterior knee pain, and ten of the fifteen were impaired by the pain. The Lysholm, Tegner, and Iowa knee scoring systems; muscle-strength measurements; and functional tests showed no significant differences between the two groups.
                Compared with a transpatellar tendon approach, a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment by a clinically relevant amount after intramedullary nailing of a tibial shaft fracture. To compare anterior and deep posterior compartment pressures during reamed and unreamed intramedullary nailing of displaced, closed tibial shaft fractures.
                Randomized prospective study.
                University Hospital/Level I trauma center.
                Forty-eight adults with forty-nine fractures treated with intramedullary nailing within three days of injury.
                After intraoperative placement of compartment pressure monitors, the tibia fractures were treated by either unreamed intramedullary nailing or reamed intramedullary nailing. A fracture table and skeletal traction were not used in any of these procedures.
                Compartment pressures and deltaP ([diastolic blood pressure] - [compartment pressure]) were measured immediately preoperatively, intraoperatively, and for twenty-four hours postoperatively.
                Compartment syndrome did not occur in any patient. Peak average pressures were obtained during reaming in the reamed group (30.0 millimeters of mercury anterior compartment, 34.7 millimeters of mercury deep posterior compartment) and during nail insertion in the unreamed group (33.9 millimeters of mercury anterior compartment, 35.2 millimeters of mercury deep posterior compartment). The average pressures quickly returned to less than thirty millimeters of mercury and remained there for the duration of the study. The deep posterior compartment pressures were lower in the reamed group than in the unreamed group at ten, twelve, fourteen, sixteen, eighteen, twenty, twenty-two, and twenty-four hours postoperatively (p < 0.05 at each of these times. A statistically significant difference between anterior compartment pressures could not be shown with the numbers available. The deltaP values were greater than thirty millimeters of mercury at all times after nail insertion in both the reamed and unreamed groups.
                These data support acute (within three days of injury) reamed intramedullary nailing of closed, displaced tibial shaft fractures without the use of a fracture table. To determine if any differences exist in healing and complications between reamed and unreamed nailing in patients with tibial shaft fractures.
                Prospective, randomized.
                Level 1 trauma center.
                Forty-five patients with displaced closed and open Gustilo type I-IIIA fractures of the central two thirds of the tibia.
                Stabilization of tibial fractures either with a slotted, stainless steel reamed nail or a solid, titanium unreamed nail.
                Nonunions, time to fracture healing, and rate of malunions.
                The average time to fracture healing was 16.7 weeks in the reamed group and 25.7 weeks in the unreamed group. The difference was statistically significant (P = 0.004). There were three nonunions, all in the unreamed nail group. Two of these fractures healed after dynamization by removing static interlocking screws. The third nonunion did not heal despite exchange reamed nailing 2 years after the primary surgery and dynamization with a fibular osteotomy after an additional 1 year. There were two malunions in the reamed group and four malunions in the unreamed group. There were no differences for all other outcome measurements.
                Unreamed nailing in patients with tibial shaft fractures may be associated with higher rates of secondary operations and malunions compared with reamed nailing. The time to fracture healing was significantly longer with unreamed nails. For unstable tibial fractures, there are many methods of surgical treatment. The efficacy of the Ender nail and the interlocking nail in the treatment of such fractures is examined.
                One hundred and seven cases of unstable tibial shaft fractures were collected for the prospective study. Randomly, 61 tibia were fixed with interlocking nails and 46, with Ender nails. The mean follow-up period was 30.5 (23 to 40) months. The results of the different treatments were compared.
                In the group with interlocking nails, the average blood loss was 265 cc; operation time was 61 minutes; hospital days were 10.4; and union time was 15.1 weeks for closed fractures and 17 weeks for Winquist-Hansen type III and IV fractures. In the group with Ender nails, the average blood loss was 135 cc, operation time was 32 minutes, hospital days were 8.3 days, and union time was 17.6 weeks for closed fractures and 22.5 weeks for Winquist-Hansen type III and IV fractures. Student t-test revealed statistically significant difference between the groups in all of the data described above. However, treatment with the different nails showed no significant difference in results for open type I and II fractures.
                Ender nail still has its superior usefulness in some aspects of treatment of less comminuted unstable tibial shaft fractures, but for the more comminuted unstable tibial shaft fractures, the interlocking nail is undoubtedly better used.