Early Changes in Nutrient Artery Blood Flow Following Tibial Nailing With and Without Reaming: A Preliminary Study

Tulane University, New Orleans, Louisiana, United States
Journal of Orthopaedic Trauma (Impact Factor: 1.8). 03/1999; 13(2):129-33. DOI: 10.1097/00005131-199902000-00010
Source: PubMed


To quantify the changes in nutrient artery blood flow following reamed and unreamed nailing of intact canine tibias.
In vivo animal study.
Eighteen dogs underwent nutrient artery blood flow measurements over a fourteen-day period. The intervention groups consisted of controls (Group I), nailing without reaming (Group II), and nailing with reaming (Group III).
Nutrient artery blood flow was measured through implantable ultrasonic blood flow probes placed around the nutrient artery of the tibia.
Nutrient artery blood flow averaged 1.94 milliliters per minute over the fourteen-day period in Group I (no reaming or nailing performed). Nutrient artery blood flow following nailing without reaming (Group II) decreased to 44 percent of baseline values immediately after the procedure. By postoperative day 1, flow had decreased to 23 percent of baseline; over the fourteen-day period, nutrient artery blood flow recovered toward baseline values. Immediately following nailing with reaming (Group III), nutrient artery blood flow measured zero milliliters per minute. Over the fourteen-day period, nutrient artery blood flow in this group averaged 39 percent of the baseline level (range 19 to 58 percent). Whereas nutrient artery blood flow recovered toward baseline values (99 percent of baseline) by fourteen days in Group II, nutrient artery blood flow measured only 26 percent of the baseline level on postoperative day fourteen in Group III.
The preliminary data suggest that nailing with reaming provides a double insult to the nutrient artery distribution.

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    • "Intramedullary nailing is commonly used for the fixation of closed and non-severe open fractures of the diaphyseal tibia (Bhandari et al., 2001), but could also be used for severe open fractures up to grade IIIB Gustilo score (Bonatus et al., 1997; Gustilo and Anderson, 1976; Henley et al., 1998; Keating et al., 1997a; Sanders et al., 1994). Unreamed intramedullary nailing avoids damage to the endosteal blood supply caused by the reaming process, lowering both the risk of an insufficient blood supply for secondary bone healing and necrosis of the cortices (Brinker et al., 1999; Hupel et al., 1998; Schemitsch et al., 1994; Schweiberer and Schenk, 1977; Stuermer, 1996). However, clinical studies have shown that unreamed intramedullary nailing tends to prolong the healing compared to reamed nailing (Finkemeier et al., 2000; Gregory and Sanders, 1995; Keating et al., 1997b; Larsen et al., 2004). "
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    ABSTRACT: The healing outcome of long bone fractures is strongly influenced by the mechanical environment. High interfragmentary movement at the fracture site is detrimental to the fracture healing process. Long bone fractures stabilized with thin intramedullary nails commonly used for unreamed intramedullary nailing might be very flexible in shear direction and therefore critical for the fracture healing outcome. The aims of this study were to simulate the shear interfragmentary movement during gait for a human tibia treated with intramedullary nailing and to investigate if this movement could be lowered by implant design modifications. The shear movement was calculated with a 3D finite element model based on computer tomograph images of a cadaver bone-implant complex of a transverse tibia fracture treated with a Stryker T2 Standard Tibial Nail. This model was validated through in vitro test results under pure shear, axial, bending and torsional loading. High shear movements of approximately 4mm were calculated during gait. These shear movements could be reduced by approximately 30% either by implant modifications or the use of a 1mm thicker nail. Combining the implant modifications with a 1mm thicker nail, the shear movements could be reduced by 54%. The increase of the fixation stiffness by using an implant material with a high Young's modulus in combination with an angle-stable nail-screw fixation helps to reduce the shear movement during gait and possibly to lower the risk of a prolonged healing time with unreamed intramedullary nailing.
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    ABSTRACT: A multicenter trial analyzed complications and odds for complications in open and closed tibial fractures stabilized by small diameter nails. Retrospective. Four Level I trauma centers. Four hundred sixty-seven tibial fractures were included in the study. There were fifty-two proximal fractures, 219 midshaft fractures, and 196 distal fractures. Breakdown into different AO/OTA groups showed 135 Type A fractures, 216 Type B fractures, and 116 Type C fractures. Two hundred sixty-five were closed fractures and 202 were open fractures. Clinical and radiographic analysis. 467 patients' tibial fractures were stabilized with small diameter tibial nails using an unreamed technique. Indications for the use of small diameter tibial nails using an unreamed technique included all types of open or closed diaphyseal fractures. The operating surgeons decided whether or not to ream based on personal experience, fracture type, and soft-tissue damage. Surgeons of Center 1 preferred to treat AO Type A and B fractures with unreamed nails, and surgeons of Centers 2, 3, and 4 preferred to treat AO Type B and C fractures with unreamed nails. Closed and open fractures were treated in approximately the same ratio. Analysis showed five (1.1 percent) deep infections (with a 5.4 percent rate of deep infections in Gustilo Grade III open fractures), forty-three delayed unions (9.2 percent), and twelve (2.6 percent) nonunions. Compartment syndromes occurred in sixty-two cases (13.3 percent), screw fatigue in forty-seven cases (10 percent), and fatigue failure of the tibial nail in three cases (0.6 percent). Fracture distraction of more than three millimeters should not be tolerated when stabilizing tibial fractures with unreamed, small-diameter nails as this increases the odds of having a delayed union by twelve times (p < 0.001) and a nonunion by four times (p = 0.057). There was a significant increase of complications in the group of Grade III open fractures (p < 0.001), AO/OTA Type C fractures (p = 0.002), and to a lesser extent in distal fractures. However, the rate of severe complications resulting in major morbidity was low.
    Journal of Orthopaedic Trauma 09/2001; 15(6):415-23. DOI:10.1097/00005131-200108000-00006 · 1.80 Impact Factor
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    ABSTRACT: Ziel der Arbeit war die Bewertung des „Reamer Irrigator Aspirator“-Prototyps in Bezug auf seine Effektivität betreffend der Reduktion der Fettverpressung und seine Auswirkungen auf die Durchblutung und Frakturheilung. Als Vergleich diente der ungebohrte AO-Nagel, als Modell die frakturierte Schafstibia. Die histologischen Präparate wurden in Bezug auf die Kallusentwicklung, das kortikale Remodelling und die Tuschefärbung sowie die Fettverteilung (Sudan III) und die kortikale Durchblutung (Procionrot) ausgewertet. Die RIA-Präparate enthielten praktisch kein Fett, wohingegen die der ungebohrten Nagelung im endostalen Drittel mit Fett verstopft waren. Die verbleibende Durchblutung der Kortikalis beim RIA-Bohrer war minimal, bei der ungebohrten Nagelung bestand im periostalen Drittel eine deutliche, im endostalen Zehntel eine schwache Restdurchblutung, in der Mitte war sie auch minimal. Nach 10 Woche bestanden in der Durchblutung keine Unterschiede. Das kortikale Remodelling nach 4 Wochen war gleich, nach 6 Wochen war es bei der ungebohrten Nagelung dreimal so groß. Die Kallusentwicklung wies keine Unterschiede auf. Es konnte gezeigt werden, dass der RIA-Bohrer effektiv die Fettverpressung verhindert, dass die Durchblutungsunterschiede akut nur gering sind und sich nach 10 Wochen kompensiert haben. Das nach 6 Wochen höhere Remodelling bei der ungebohrten Nagelung spricht für eine Schädigung der Kortikalis durch die höhere Fettverpressung. Die Frakturheilung ist bei beiden Nagelungssystemen gleich gut. Summa summarum weist der „Reamer Irrigator Aspirator“ durch die genauso gute Frakturheilung bei praktisch keiner Fettverpressung gegenüber der ungebohrten Nagelung Vorteile auf, die eine klinische Anwendung interessant erscheinen lassen.
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