nailing compound fractures when / safety evidence dr.g.s.kulkarni miraj
TRANSCRIPT
Nailing compound fractureswhen / safety evidence
DR.G.S.KULKARNI MIRAJ
HISTORY of open fractures• American Civil War
Mortality 26% • France – Russian war
13000 Amputee
Nailing in open fractures
1. Improved technique debridement.2. Use of AB bead pouch and Rod3. Vaccume assisted closure4. Newer designs of nails & plates.5. Perioper. AB
Corner stone of Open fracture-Debridement
1. Wound - Extend longitudinally-2. Exploration Fasciotomy3. Debridement4. Irrigation 5. AB Beads 6. VAC – not a substitute
Adv. nailing in open #1. Early stabilization of open fracture
controls pain,swelling, mobility
inflammation2. Mobility-Further soft tissue damage3. Early mobilization of jt & pt. 4 CPM
IMN Adv.1.Biomechanically superior,
maintain L, alignment and rotation
2.Early wt. bearing3.Less rate of secondary surgery
Adv. of immediate IF
Unkinks A,V and lymphatics , improves circulation at fracture zone
Ext. Fix –meta-analysisAdv : union - 94 % infection - 16% chro. Osteo - 4% -Giamondis JBJS, Br. 2006
Complication of Ext. Fix1. Pin loosening2. Pin tract inf. 32 %3. Mal-union 4. Exchange nailing- inf -- 15 to 30%5. “Non-union machine “
IMNIMN is a safe, effective method
for open fracture I, II, III A & B S.Malvin JAAOS, Feb 2010
Reamed V/s Unreamed
• Reaminng-- Adv 1. larger diameter – better fracture stability 2. Implant failure less 3. Reaming deposit B.G.
4. Periosteal blood supply ++
Reaming .• Metaanalysis failed to show an
increased risk of re-operation• No increased rate of infection or
nonunion - Bhandari Et al
JBJS B 2001 : 62 - 68
Multicentric level 1 study• open fractures 460 • Reamed 210• Unreamed 196• Does not support superiority of either. SPRINT Group JBJS Am 2008 Debate is ongoing
• Reamed Disadv - 1. Reduced intramedullary blood supply, but Periosteal blood supply ++
2. Thermal necrosisa) use sharp reamers, increment
by 0.5 mm b) gentle reaming –back & forth
Poor result of IMN1. Inadequate debridement2. Inappropriate soft tissue closure3. Thermal necrosis4. Severe contamination + late arrival These are contra-indications
Literature • 143 cases of open tibial shaft
fractures.Primary IMN has Favourable results.• Deep infection – 3 % - Koker & Tornetta JOT 2007
Exchange ex fix to IMN
• Safety period 10 days till soft tissue recovery
• < 14 days ( Varies from 7 to 28 days)• Shorter period reduces infection rate
- JS Melion et al JOT Feb 2010
Do not do primary IMN• Severe contamination• Inadequate debridement• Delayed arrival• AB Rod + Ex. Fix • 7-10 days IMN
JAGRUTI M
DAY 1Debride A-B Rod AO Ex Fix 1st VAC
JAGRUTI MANCHAREKAR
DAY 1
DAY 5
JAGRUTI M
After 3 changes of VAC, 2nd Skin graft
DAY 9
JAGRUTI M
After 1 yr
VAC & I.F. OF OPEN FRACTURE
• With VAC it is possible to nail or plate IIIB open #
as VAC is an excellent interval coverage
• Almost no role of plaster splint or plaster cast with window in open fracture.
External Fixator in Open #s• Advantages 1. Pins away from fracture zone 2. No additional open surgery 3. Access to wound dressing and plastic surgery 4. Early mobilisation
External Fixator• Disadvantages :1. Pin tract infection2. Risk of infection of later ORIF3. Soft – tissue impaling stiff jt.4. Pin loosening Ex fix as a definative treat not
favoured
AC
VAC
Nailed on day 1 of injury
Amar Sawant
15 days old
AMAR SAWANTAmar Sawant
AMAR SAWANTAmar Sawant
Amar Sawant 146213
Chavan chandrakant - 153242
Chavan chandrakant - 153242
Kolekar Parmeshwar - 146071
Hebbal Hasan 142617
Open fracture+ pilon IMN on day 1
Hebbal Hasan 142617
Both united
CONCLUSION
• Corner stone of fracture debridement• IMN is a safe, effective method • Two stage nailing –I) AB rod II) ILIMN
a) severe contaminationb) delayed arrival