JIIMS final 19 Introduction The tibia is commonly fractured bone frequently caused by high-energy trauma leading to the complications and major 1disabilities. Surgeons have employed different types of intramedullary nails over past 500 years. Today, the intramedullary interlocking tibial nailing is the leading modality of treatment because of its biomechanical advantage over the other 2modalities. This procedure is done in the advanced centers under the image 3,4,5intensifier. However, there is no facility of C- arm image intensifier in the operation theatre at most of the tertiary level hospitals in Pakistan. Most of the peripheral hospitals do not even have portable X- ray facility. The purpose of this study was to study the success rate of intramedullary nailing of tibial shaft fractures without the aid of image intensifier. Tanna et al reported a method for locked tibial nailing without image intensifier in 1994, using hollow t u b u l a r n a i l s w i t h n o s l i t a n d anteroposterior holes for the locking 6screws. With newly designed interlocking nails, it is now feasible to achieve interlocking nail i n s e r t i o n w i t h o u t t h e a i d o f a n intraoperative image intensifier, simply by the use of an external jig and slot finder eg the SIGN (Surgical Implant Generation Network) system. Successful interlocking nailing using such method should not only improve the quality of fracture care, but should also lead to a reduction of exposure 7,8,9to intra-operative ionizing radiation. SIGN nail is not freely available in our ORIGINAL ARTICLE ABSTRACT Introduction: Internal fixation with interlocking nails is commonly performed using an image intensifier which is expensive and is not readily available in most resource-poor countries of the world. Objective: The aim of this study was to achieve internal fixation with interlocking nail without the use of an image intensifier and to study the mean union time and complications in these patients. Study Design: It was a quasi-experimental study. Place and Duration of Study: This study was carried out at Railway General Hospital (RGH), Rawalpindi over duration of two years from January 2010 till December 2011. Materials and Methods: 22 closed tibial shaft fractures were fixed with interlocking intramedullary nails without using an image intensifier. Results: The study included 22 closed tibial shaft fractures. The mean age of the patients was 39.4±9.97 years and the range was 2255 years. There were 8 females and 14 males. Postoperative plain radiographs confirmed that all of the cases had satisfactory positioning of the inserted nails and interlocking screws. The mean union time was 13.8±4.2 weeks. Two cases of delayed union were seen (union occurred at 24 and 28 weeks). One case of infection occurred and presented with an infrapatellar abscess. Shortening of 12 mm and valgus deformity occurred in one case due to loosening of distal screw. Conclusion: Internal fixation with interlocking of tibial shaft fractures can be achieved successfully without an image intensifier. Key Words: Tibial Fracture, Interlocking, Intramedullary Nails --------------------------------------------------- Closed Interlocking Tibial Nailing without using an Image Intensifier Sohail Iqbal Sheikh, Muhammadullah, Arab Khan, Javed Iqbal Correspondence: Prof. Dr Sohail Iqbal Sheikh Head of Orthopedics Department Islamic International Medical College Pakistan Railway General Hospital, Rawalpindi 19 20 region and if available it is expensive, so we started doing interlocking nailing of tibia w i t h o r d i n a r y t i b i a l i n t e r l o c k i n g instruments which are freely available and inexpensive. This work, which describes my experience in using this method, is expected to contribute to knowledge in our sub region, since there is a paucity of literature on this subject matter. This work will also help to introduce this mode of treating fractures in resource-poor regions of the world, where image intensifiers are not widely available. T h i s q u a s i - e x p e r i m e n t a l s t u d y w a s conducted over duration of two years from January 2010 to December 2011 in the Orthopedic Unit of Railway General Hospital (RGH) Rawalpindi. The study was conducted after approval from the hospital ethical committee.Tibial shaft fracture patients presenting to the emergency department were recruited into the study by consecutive non-probability sampling and a n i n f o r m e d c o n s e n t w a s t a k e n . Anteroposterior (AP) and lateral view radiographs of tibial shaft incorporating the entire length of the lower leg from knee to ankle were obtained. Closed tibial shaft fractures with significant malrotation (=10 degrees of rotation in any plane), malalignment (angulated =10 degrees), and displacement (=5 mm of displacement) were opted for operative management by interlocking nailing. Open fractures or severely comminuted fractures were excluded. Moreover fractures with evidence of neurovascular injury, compartment syndrome and fractures with dislocation of the knee or ankle were excluded. Closed, Material and Methods well-aligned, no displaced tibial shaft fractures were treated with a long leg cast and also were not included in our study. Patients were operated under spinal anesthesia. The interlocking nails were inserted as follows; under tourniquet the patient is placed supine and the leg of the patient hangs downwards over the edge of the table making 90 degrees of flexion at knee joint. A skin incision is made over patellar tendon and the patellar tendon is split longitudinally. Hole is made in upper end of tibia with bone awl, after this guide wire is inserted into the medullary cavity. One assistant pulls distal end of fracture downwards and guide wire is pushed through distal end of fracture. Grating feeling is appreciated while guide wire passes into distal fragment and stability is confirmed. Reaming of medullary cavity is done in increasing numbers. After this, size of nail is measured by putting nail over leg from tibial tuberosity to just above ankle. Then another nail of similar size is kept aside. One of the nails is inserted into medullary cavity after attaching it to proximal jig of tibial interlocking nail. Second nail is placed outside the tibia closed to skin and drill bit is passed through jig and then it passes through nail placed outside and then through skin and is drilled into bone. This is checked by passing guide wire through medullary cavity. The drill bit is retrieved and guide wire is passed distally till the lower end of nail. Then upper end of guide wire is marked with help of artery forceps. Another hole is drilled through distal I/L hole by passing drill bit through distal hole in the nail placed over skin, then it is drilled into the inner nail which is confirmed by pushing guide wire, if the 20 21 artery forceps mark is lying away from jig, it confirms that the drill is in the hole of inner nail. Then screw is passed, guide wire is removed and screw through upper hole is passed. Finally wound is closed. All patients had a similar preoperative regimen of intravenous Cephradine continued for 5 days postoperatively. Early physiotherapy of all involved joints, as well as early weight bearing, was encouraged. No cast or brace was applied. Analysis of the outcome of treatment with respect to the time of fracture union and the presence of complications was performed. Fracture union was assessed clinically and radiologically at 6 weeks and 3 months, and then subsequently at monthly intervals. The fracture was considered to have united when there was no pain or tenderness, when there was no abnormal movement at the fracture site and when bridging callus was visible on a plain radiograph. A fracture was considered to have normal union if there was osseous union in four months or less and delayed union if the fracture healed between four and eight months post operatively. A fracture that had not healed by eight months was considered to have a non-union. All of our patients were followed-up for at least 12 months. Data was entered into a proforma and was analyzed using SPSS 12. The study included 22 closed tibial shaft fractures. The mean age of the patients was 39.4±9.97 years and the range was 2255 years. There were 8 (36.4%) females and 14 ( 6 3 . 6 % ) m a l e s . P o s t o p e r a t i v e p l a i n radiographs confirmed that all of the cases had satisfactory positioning of the inserted nails and interlocking screws. The mean Results union time was 13.8±4.2 weeks. Two (9.1%) cases of delayed union were seen (union occurred at 24 and 28 weeks). This was in comminuted fractures of distal one third of tibia. One case (4.5%) of infection occurred nine months after union and presented with an infrapatellar abscess, which did not communicate with the knee joint. This was drained and the nail removed. Shortening of 12 mm and valgus deformity occurred in one (4.5%) due to loosening of distal screw. The most common cause of morbidity and mortality in the most productive period of life worldwide are road traffic accidents 10causing fractures. It is not surprising, therefore, that these fractures occur mostly in people aged between 20 and 50 years. The sex ratio distribution of 1.75:1 for male:female is also in keeping with other 11reports and further emphasizes the greater vulnerability of males to trauma. The availability of the appropriate treatment modality could be of utmost concern to any practicing orthopaedic surgeon in most resource-poor countries of the world, including the Indian subcontinent. The use of interlocking nails for fractures of long bones has increased and indeed has become the gold standard for care of unstable long b o n e f r a c t u r e s . H o w e v e r , i t s m a i n drawbacks are cost and the need for a reliable intraoperative image intensifier 12,13support. There are now nails that can be 14locked with the aid of external jigs. In our study, 100% of the fractures were fixed without the use of an image intensifier with the satisfactory placement of nails and screws in all cases. Complications were few and mild. Infection could have been avoided Discussion 21 22 by improving the aseptic technique. Delayed union occurred in the distal third fracture of a tibia with severely comminuted fracture line. The blood supply to this region is very precarious and could be associated with an increase in the incidence of non- union. There was no case of nail or screw breakage in this study, however screw loosening resulted in valgus deformity and shortening in one case.Our results are in 15,16,17agreement with other works. Only few studies were available for comparison. Ikem et al15 recorded two cases of superficial wound infection, two cases of delayed union 16and a case of screw loosening Giri. in 2007 reported the success of distal locking in the intramedullary nailing of tibial shaft fractures with the aid of distal aiming device, where the distal hole was directly visualized after proper drilling. The union 17time in an average was 4 months. Giri. in 2008 in another study reported that after using interlocking nails for fractures of tibial shaft the complication was distal screw loosening leading to valgus deformity and shortening in one case. However, no local study is available for comparison.The e x c l u s i o n o f a n i m a g e i n t e n s i f i e r automatically eliminates the harmful effect of an increased dose of radiation to both the orthopaedic surgeon and the patient. Radiation times were recorded to average Table-I: Complications after closed Tibial Nailing about eight seconds, the longest time being 36 seconds in the study by Court et al during interlocking nailing of tibial fractures.3 It has the added advantage of reduced cost to the patient whilst, at the same time, ensuring high-quality fracture care. We conclude that internal fixation with interlocking of tibial shaft fractures can be achieved successfully without an image intensifier. 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