Copyright 1990 by The Journal ofBone and Joint Surgery, Incorporated

External Fixation and Delayed Intramedullary Nailing

of Open Fractures of the Tibial Shaft
A SEQUENTIAL PROTOCOL*

BY PIOTR A. BLACHUT, M.D., F.R.C.S.(C)t, ROBERT N. MEEK, M.D., F.R.C.S.(C)t,

AND PETER J. O’BRIEN, M.D. , F.R.C.S.(C)t, VANCOUVER, BRITISH COLUMBIA, CANADA

From the Department of Orthopaedics, University of British Columbia, Vancouver General Hospital, Vancouver

ABSTRACT: Between 1983 and 1989, forty-one open medullary infection. Delayed insertion of intramedullary
fractures of the tibial shaft were treated with d#{233}bride- nails after a period of external fixation has been mentioned
ment and provisional external fixation, followed by de- in several reports on open tibial fractures”4’9”9’20’26’27’33’38. To
layed soft-tissue closure and subsequent intramedullary our knowledge, McGraw and Lim were the first to focus
nailing with reaming. The average duration of external on this technique, and they reported a high rate of infection
fixation was seventeen days (range, six to fifty-two days). in a large series of patients26.
The average time between removal of the fixator and At our institution, a sequential protocol consisting of
intramedullary nailing was nine days (range, zero to d#{233}bridement, external fixation, closure of the wound, and
twenty-four days). intramedullary nailing with reaming and interlocking nails
of thirty-nine patients who had adequate follow- has been used for selected patients who have an open frac-
up, two (5 per cent) subsequently had a deep infection. ture of the tibial shaft. The purpose of this retrospective
Both infections healed, with retention of the nail and study was to analyze the results in a consecutive series of
without chronic osteomyelitis. There were two non- patients.
unions and one delayed union. Satisfactory alignment
was achieved in thirty-seven patients (95 per cent). Materials and Methods
This sequential protocol for treatment, which in- Between 1983 and 1989, 191 patients who had an open
volved a short period of external fixation and thus mm- tibial fracture for which intramedullary nailing was appro-
imized colonization of the pin tracks, yielded excellent priate were managed at our institution. Forty-one fractures
results and a low rate of infection. in forty-one patients were treated with intramedullary nail-
ing with reaming after provisional external fixation. The
The treatment of open fractures of the tibial shaft re- system for retheval of clinical data did not allow determi-
mains controversial. External fixation is the standard treat- nation of the number of patients for whom the protocol was
ment for all but Grade-I’4 fractures. However, despite many started but not completed due to failure of any step of the
refinements in this technique, it has been associated with treatment. The patients were treated with the protocol at the
numerous complications, including problems at the sites of discretion of the staff orthopaedist. Alternative treatment
the pins, non-union, delayed union, malunion, and infec- was routinely used for patients who had a history of infection
tion”3’6”#{176}”13’9’2022’24’39 Alternative methods of manage- or an active infection in the limb and for patients who were
ment, including primary internal fixation with intramedul- seen twenty-four hours or more after injury. Other patients
lary nails7”30’33”#{176} or a plate” and delayed internal fixation, were treated with alternative methods due to the preference
have been advocated. The biomechanical and biological of the staff. One patient who had multiple injuries was
advantages of intramedullary fixation of closed fractures of selected for the protocol but he died of a massive pulmonary
the tibial shaft have been well documented, and these ad- embolism before the treatment was completed. Another pa-
vantages have been reflected by excellent clinical re- tient was lost to follow-up. Therefore, the results in thirty-
21 2. 16. 17.21 .23.25.28,30.32.33.3638.41 43 nine patients who had thirty-nine fractures were analyzed.
The primary use of nails for fixation of open fractures
Treatment Protocol
of the tibia is very controversial because of the risk of
When the patient was first seen, standard emergency
* No benefits in any form have been received or will be received from assessment was performed, sterile dressings were applied
a commercial party related directly or indirectly tothe subjectofthis article.
No funds were received in support of this study.
to all wounds, the extremity was splinted, and antibiotics
t Department of Orthopaedics, Vancouver General Hospital, Third and prophylaxis against tetanus were administered.
Floor, Laurel Street Pavilion, 910 East 10th Avenue, Vancouver, British
Columbia V5Z 4E3, Canada. Please address requests for reprints to Dr.
Emergency operation was done, with a goal of d#{233}-
Blachut. bridement ofthe wound within six hours of injury. However,

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730 P. A. BLACHUT, R. N. MEEK, AND P. J. O’BRIEN

-w
I

FIG. 1-A FIG. 1-B

Fig. 1-A: A thirty-five-year-old man sustained a Grade-lIlA open fracture in a motorcycle accident.
Fig. 1-B: External fixation was followed by delayed primary closure with a local bipedicle skin flap on the fifth day after injury.

FIG. 1-C FIG. 1-D

Fig. 1-C: The fixator was removed and calcaneal traction with a BOhler-Braun frame was applied on the seventeenth day.
Fig. l-D: On the twenty-seventh day, intramedullary nailing with interlocking nails was performed in conjunction with insertion of a bone graft via
the medullary canal.

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 EXTERNAL FIXATION AND DELAYED INTRAMEDULLARY NAILING 731

FIG. l-E
Fig. 1-E: Six months after the nailing, a delayed union was treated with posterolateral bone-grafting and removal of the interlocking nails.
Fig. 1-F: Union was achieved.

this was frequently not possible due to the referral nature a Grade-I or II injury and a first-generation cephalosporin
of our practice, which serves a large area including British and an aminoglycoside, for those who had a Grade-Ill in-
Columbia and the Yukon Territory. The site of the wound jury.
was thoroughly excised, debrided, and irrigated, and a sin- After the nailing, rehabilitation included mobilization
gle half-pin external fixator was applied. Early in the course ofthe adjacentjoints as soon as possible. The time to weight-
of the study, a number of delta-configuration frames were bearing varied according to the fracture pattern. Unless it
used, but we now recommend the use of an anterior half- was contraindicated by other injuries, weight-bearing was
pin frame only. permitted for all patients within four to six weeks after the
The wound was left open and was repeatedly debrided nailing.
as necessary. An attempt was made to obtain soft-tissue Thirty patients were male and nine were female. The
closure by the fifth to seventh day. When the wound had ages ranged from sixteen to eighty-two years and averaged
healed satisfactorily, usually within five to seven days after thirty-three years. Eighty per cent of the patients were be-
closure, the external fixator was removed and the limb was tween sixteen and forty years old. The mechanisms of injury
placed in a cast or, if the fracture was grossly unstable, in were mainly automobile, motorcycle, and pedestrian-motor
calcaneal traction. The sites of the pins and the wounds vehicle accidents.
were monitored for an additional week; when they were dry Sixteen patients were transferred from other institu-
and if there was no infection, closed intramedullary nailing tions, and five of them had been operated on before the
with reaming was performed. Interlocking nailing was used transfer. The other twenty-three patients were seen primarily
at the discretion of the attending surgeon. at the Vancouver General Hospital.
The patient remained in the hospital for the duration The left leg was involved in twenty-one patients and
of the treatment except when a free vascularized flap had the right leg, in eighteen. Twelve fractures involved the
been used. In these patients, because of concern for the middle of the tibial shaft; one, the distal third; six, the
vascularity of the flap, nailing was delayed for four to six junction between the proximal and middle thirds; fourteen,
weeks, during which time the patient was not hospitalized. the junction between the middle and distal thirds; and six
With every operative procedure, prophylactic anti- extended over several levels. The classification of Winquist
biotics were given for forty-eight to seventy-two hours. A et al.42 was used to categorize comminution as Grade 0 in
first-generation cephalosporin was used for patients who had four patients, Grade 1 in three, Grade 2 in eleven, Grade

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732 P. A. BLACHUT, R. N. MEEK, AND P. J. O’BRIEN

Fig. 2-A: A twenty-five-year-old man sustained a Grade-Il open fracture while playing soccer.
Fig. 2-B: Care of the wound and external fixation were carried out immediately, and delayed primary closure of the wound was performed at four
days.

3 in eleven, and Grade 4 in ten. With the classification of unlocked in one patient, statically interlocked in twenty-
Gustilo et al.14”5, five wounds were classified as Grade I two patients, and dynamically interlocked in sixteen pa-
open; twenty-two, Grade II open; seven, Grade lIlA open; tients. In one patient who had segmental loss of bone, an
five, Grade IIIB open; and none, Grade IIIC open. Twenty- intramedullary bone graft was inserted at the time of nailing.
six (67 per cent) of the patients had multiple injuries, and For the patients who had an isolated injury, the stay
twenty of them had associated injuries to the lower extrem- in the hospital averaged thirty days (range, eleven to fifty-
ities. Nine of these injuries were ipsilateral to the open tibial five days). For the total group of patients, it averaged forty
fracture. days (range, eleven to 137 days).
There were minor deviations from the standard pro-
Results
tocol. One patient did not receive prophylactic antibiotics.
In four patients, a unilateral delta frame (with half-pins) Fracture-Healing
was used for external fixation instead of the simple anterior Thirty-six of the thirty-nine fractures healed within six
half-pin frame that was used for the remaining thirty-five months after injury. One patient (Figs. 1-A through 1-F)
patients. who had lost a three-centimeter-long segment of bone
Closure of the wound was delayed for an average of needed a posterolateral bone graft for delayed union six
seven days (median, five days; range, two to thirty-eight months after the nailing. Two patients had a non-union. In
days). A split-thickness skin graft was used in ten patients; one of them, a Grade-IIIB open fracture had been treated
delayed primary closure, in eighteen patients; and a flap, in with a latissimus dorsi free flap. Twenty-four months after
ten patients. The flaps included four local skin flaps (one the nailing, this patient had only mild symptoms, but there
rotation and three bipedicle), four local muscle flaps, and was radiographic evidence of non-union. In the second pa-
two free vascularized (latissimus dorsi) muscle flaps. One tient, the nail fractured at nine months and an exchange
wound was allowed to close by secondary intention. nailing was done. The fracture was malunited and an Os-
The external fixator was removed an average of sev- teotomy was needed to correct the alignment of the tibia.
enteen days (median, fourteen days; range, six to fifty-two
Infection
days) after injury and an average of ten days after closure
of the wound. Intramedullary nailing was performed an In two patients, an infection developed in the pin track
average of twenty-six days (median; twenty-four days; of the external fixator. Both infections healed rapidly, and
range, twelve to seventy-three days) after injury and an no infection developed after the nailing in either patient.
average of nine days (median, seven days; range, zero to One superficial infection developed after nailing, and it re-
twenty-four days) after removal of the fixator. The nail was sponded to antibiotics.

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 EXTERNAL FIXATION AND DELAYED INTRAMEDULLARY NAILING 733

FIG. 2-C
Fig. 2-C: On the ninth day, intramedullary nailing with interlocking nails was performed immediately after removal of the external fixator.
Fig. 2-D: Infection ensued and repeated sequestrectomies were done, but the nail was retained until the fracture had united. After union, the nail
was removed. There was no subsequent infection.

Two patients had a deep infection. One of them had Both patients who had a deep infection had received
had a Grade-I! open fracture (Figs. 2-A through 2-D), and first-generation cephalosporins for prophylaxis during the
intramedullary nailing was done immediately after the cx- initial treatment.
ternal fixator was removed (nine days after injury), before
Alignment
the pin tracks healed. Twenty-five days after injury, an
abscess was found at the site of the open wound. Incision Vans or valgus angulation of S degrees or less, anterior
and drainage was done, and Staphylococcus aureus grew or posterior angulation of 10 degrees or less, and shortening
on culture. Another d#{233}bridement was needed to control the of less than one centimeter were the criteria for satisfactory
infection. At eight months, the nail was removed without alignment on radiographic assessment. Radiographs were
complication, and the infection did not recur. unavailable for one patient. At the most recent follow-up,
The other patient who had a deep infection had had a thirty-six patients had satisfactory alignment. The two re-
Grade-lI open fracture. The external fixator had been in maining patients, both of whom had had Grade-IV corn-
place for nineteen days, and intramedullary nailing had been minution of the fracture, had a malunion. One of them had
carried out five days after it was removed. Three months a corrective osteotomy, as described already.
after injury, the patient had erythema and scant drainage
Additional Operations
from the open wound. Staphylococcus aureus grew on cul-
ture. Cloxacillin, administered orally, controlled the infec- Additional operative procedures included bone-graft-
tion, but it recurred several times and was treated with oral ing in two patients, removal of the nail from fourteen, dy-
administration of antibiotics. Almost two years after the namization of statically interlocked nailing in eight, revision
injury, the nail was removed and a sequestrectomy was of the interlocking nails in one, and below-the-knee am-
done. The operation was complicated by septic arthritis, putation in one. One of the two patients who had postero-
with Staphylococcus aureus again being the causative or- lateral bone-grafting had received an intramedullary bone
ganism, and additional d#{233}bridement and intravenous admin- graft at the time of the initial nailing (Figs. 1-A through 1-
istration of antibiotics were needed. In the subsequent five F). In the patient who had revision of interlocking nailing,
years, there were no more problems with infection. the nail had been dynamically interlocked with proximal

VOL. 72-A, NO. 5, JUNE 1990

734 P. A. BLACHUT, R. N. MEEK, AND P. J. O’BRIEN

screws only and it proved to be unstable rotationally. This recommend this technique.
necessitated derotation and static locking. Healing pro- Puno et al.33 reported one infection in a patient in whom
ceeded uneventfully. Below-the-knee amputation was per- nailing had been done thirty-six hours after the frame was
formed on a patient who was receiving psychiatric treatment removed. They did not report how many delayed nailing
and who had chronic osteomyelitis of the foot after an ip- procedures had been done, but they thought that the oper-
silateral fracture-dislocation of the mid-part of the foot. The ation was satisfactory as long as five to seven days elapsed
tibial fracture had healed. between removal of the frame and intramedullary nailing.
In a review ofintramedullary nailing oftibial fractures, Bone
Other Complications and Johnson4 found that five of the nailing procedures had
Other complications included two pulmonary emboli been delayed and one of them had been followed by a deep
and an injury to the posterior tibial nerve. The patients who infection. In this patient, who had a delayed union, the frame
had the pulmonary emboli were treated with vena caval had been in place for eight months. Bone and Johnson
filters, and the sequential protocol was completed. The in- suggested a period of seven to ten days between removal
jury to the posterior tibial nerve occurred when the external of the frame and nailing, with additional postponement in
fixator pins were inadvertently inserted too deeply. At the the presence of any problems with pin sites. Rommens and
most recent follow-up, the patient had a residual partial loss Schmit-Neuerburg35 described the case of one patient who
of sensation on the plantar aspect of the foot. had delayed nailing four months after external fixation and
The delay in nailing resulted in no technical compli- minimum internal fixation; this fracture healed uneventfully.
cations, and no problems were related to the use of calcaneal To our knowledge, McGraw and Lim26 reported the
traction. only study that dealt specifically with nailing after external
fixation. In only nine of their sixteen patients was nailing
Discussion done as part of the original plan of treatment. The average
The good results in our thirty-nine patients corroborate time to intramedullary nailing was seven weeks. The rate
the effectiveness of sequential treatment of open tibial frac- of infection was 44 per cent and the rate of non-union was
tures. If the wound is closed expeditiously and the external 50 per cent. As far as we know, all other reports have
fixator is removed early, the benefits of intramedullary nail- described intramedullary nailing as a late technique for the
ing with reaming can be obtained without an unacceptably treatment of complications of external fixation. All have
high incidence of infection. A study of a larger series of involved long periods of external fixation before nailing.
Grade-Ill open fractures is needed to confirm the efficacy We found that a protocol of early delayed nailing (after
of this treatment for more severe open fractures of the tibia. an average of seventeen days of external fixation) gave
In 1975, Karlstr#{246}m and OlerucV9 were the first to men- excellent results, without a high rate of infection. Function
tion intramedullary nailing after external fixation, to our was restored rapidly, and many of the complications of
knowledge. They reported on a single patient who had a external fixation, including problems at the sites of the pins,
three-month-old fracture, the treatment of which was com- malunion, delayed union, and non-union, were avoided.
plicated by deep sepsis. Clancey and Hansen8, Velazco et The disadvantages of the technique are the need for several
al.’#{176},
and Aho et ‘ reported on one, two, and five patients, operative procedures and a longer period of hospitalization.
respectively. All of the patients had had a delayed union, Our experience, as well as that of others4”6’23’28’33, has
but the results were not elaborated on. Aho et al. concluded suggested that treatment of low-grade open fractures by
that intramedullary nailing was a reliable technique for the primary intramedullary nailing with reaming of the tibia
treatment of persistent non-union after failure of bone-graft- yields excellent results, but the technique may be contrain-
ing and fibular osteotomy. In 1983, KarlstrOm and Olerud2#{176} dicated for more severe fractures. The sequential treatment
reported on two additional patients, one of whom had a deep that was used in this study provided a satisfactory alternative
infection after delayed nailing. As a result, they did not for the treatment of open tibial fractures.

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