Nailing compound fractures when / safety evidence DR.G.S.KULKARNI MIRAJ

American Civil War Mortality 26% France – Russian war 13000 Amputee HISTORY of open fractures American Civil War Mortality 26% France – Russian war 13000 Amputee

Nailing in open fractures Improved technique debridement. Use of AB bead pouch and Rod Vaccume assisted closure Newer designs of nails & plates. Perioper. AB

Corner stone of Open fracture-Debridement Wound - Extend longitudinally- Exploration Fasciotomy Debridement Irrigation AB Beads 6. VAC – not a substitute

Adv. nailing in open # Early stabilization of open fracture controls pain,swelling, mobility inflammation 2. Mobility-Further soft tissue damage 3. Early mobilization of jt & pt. 4 CPM

IMN Adv. Biomechanically superior, maintain L, alignment and rotation Early wt. bearing Less rate of secondary surgery

Adv. of immediate IF Unkinks A,V and lymphatics , improves circulation at fracture zone

Ext. Fix –meta-analysis Adv : union - 94 % infection - 16% chro. Osteo - 4% -Giamondis JBJS, Br. 2006

Complication of Ext. Fix Pin loosening Pin tract inf. 32 % Mal-union Exchange nailing- inf -- 15 to 30% “Non-union machine “

IMN IMN 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 necrosis a) use sharp reamers, increment by 0.5 mm b) gentle reaming –back & forth

Poor result of IMN Inadequate debridement Inappropriate soft tissue closure Thermal necrosis 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

Debride A-B Rod AO Ex Fix 1st VAC DAY 1 JAGRUTI M

JAGRUTI MANCHAREKAR DAY 1 DAY 5

After 3 changes of VAC, 2nd Skin graft JAGRUTI M DAY 9 After 3 changes of VAC, 2nd Skin graft

After 1 yr JAGRUTI M

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 : Pin tract infection Risk of infection of later ORIF Soft – tissue impaling stiff jt. Pin loosening Ex fix as a definative treat not favoured

VAC AC V

1 Nailed on day 1 of injury

Amar Sawant 15 days old Amar Sawant

AMAR SAWANT Amar Sawant

AMAR SAWANT Amar Sawant

Amar Sawant 146213

Chavan chandrakant - 153242

Chavan chandrakant - 153242

Kolekar Parmeshwar - 146071 Kolekar Parmeshwar - 146071

Open fracture+ pilon IMN on day 1 Hebbal Hasan 142617

Both united Hebbal Hasan 142617

CONCLUSION Corner stone of fracture debridement IMN is a safe, effective method Two stage nailing –I) AB rod II) ILIMN a) severe contamination b) delayed arrival