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Trauma: G. I. Drosos, M. Bishay, I. A. Karnezis, and A. K. Alegakis Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures J Bone Joint Surg Br 2006; 88-B: 227-231 [Abstract] [Full text] [PDF]

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Factors affecting healing of tibial shaft fractures

Antti S Kyrö, Hannu Tiusanen   (15 May 2006)

Nail diameter and dynamisation

Dr. Anil Agarwal   (13 February 2006)

Factors affecting healing of tibial shaft fractures 15 May 2006
Antti S Kyrö, Chief Orthopaedic Surgeon South-Karelia Central Hospital, Hannu Tiusanen Send letter to journal: Re: Factors affecting healing of tibial shaft fractures antti.kyro{at}ekshp.fi Antti S Kyrö, et al.	Sir, We read this article with interest. The authors have studied meritoriously the influence of the age and gender of the patient, the details of the injury and of the method of the treatment. However, there are other factors affecting the healing time and the occurrence of failure of union of tibial shaft fractures. A heavy smoking habit,1-3 substantial alcohol consumption,4 and occlusive arterial disease of the fractured lower limb5,6 are factors which delay the healing of tibial shaft fractures. The use of non-steroidal anti-inflammatory drugs7 delays diaphyseal fracture healing. In primarily conservatively-treated tibial shaft fractures, after AO classification of the fracture, the second most important factor affecting the healing time was the fact that the patient smoked, and it was clearly a more important factor than the age or gender of the patient.1 We do not believe that all of the important factors affecting healing time are studied in this article. The inclusion in the analysis of at least the aforementioned characteristics of the patients would have made it more complete. A. Kyrö, Chief Orthopaedic Surgeon, South-Karelia Central Hospital, Lappeenranta, Finland. H. Tiusanen, Orthopaedic Surgeon, Turku University Hospital, Paimio, Finland. 1. Kyrö A, Usenius J-P, Aarnio M, Kunnamo I, Avikainen V. Are smokers a risk group for delayed healing of tibial shaft fractures? Ann Chir Gynaecol 1993;82:254-62. 2. Schmitz MA, Finnegan M, Natarajan R, Champine J. Effect of smoking on tibial shaft fracture healing. Clin Orthop 1999;365:184-200. 3. Adams CI, Keating JF, Court-Brown CM. Cigarette smoking and open tibial fractures. Injury 2001;32:61-5. 4. Nyquist F, Berglund M, Nilsson BE, Obrant KJ. Nature and healing of tibial shaft fractures in alcohol abusers. Alcohol Alcoholism 1997;32:91-5. 5. Deitz DM, Taylor LM, Beals RK, Porter JM. Role of revascularization to treat chronic nonhealing fractures in ischemic limbs. J Vascul Surg 1989;10:535-40. 6. Dickson K, Katzman S, Delgado E, Contreras D. Delayed unions and nonunions of open tibial fractures. Correlation with arteriography results. Clin Orthop 1994;302:189-93. 7. Giannoudis PV, MacDonald DA, Matthews SJ, et al. Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg [Br] 2000;82-B:655–8.
Nail diameter and dynamisation 13 February 2006
Dr. Anil Agarwal, Senior research associate UCMS & GTB Hospital, Delhi, India Send letter to journal: Re: Nail diameter and dynamisation rachna_anila{at}yahoo.co.in Dr. Anil Agarwal	Sir, I very much enjoyed reading this article. It was interesting to note that comminution, dynamisation and failed locking screws increase the risk of failure of union. However, there are certain queries I would like to raise. 1. The authors have not detailed the nail diameters in the article. Drosos et al used reamed locked intramedullary nailing for the tibial fractures in their series. Klein et al reported 31% reduction of cortical circulation using unreamed nails compared to 71% reduction after reaming.1 As the fracture comminution increases, the risk of cortical necrosis tends to increase with a snugly-fitted reamed nail.2 Thus nail diameter is an important determinant of fracture union in comminuted fractures (especially grade III and IV) and must be included in statistical analysis. 2. Cases dynamically locked at initial surgery had a shorter period of healing (average 7.2 weeks) compared to those statically locked. When the static locked cases were dynamised (average 17.8 weeks) after initial surgery, the union hastened. To state explicitly that dynamisation increases the risk of failure of fracture union is perhaps erroneous, since dynamisation was always carried after a delay of several weeks in cases not showing satisfactory progression of healing. A delay in union is expected in these cases. A. Agarwal, Senior Research Associate, UCMS & GTB Hospital, Delhi, India. 1. Klein MP, Rahn BA, Frigg R, et al. Reaming versus non-reaming in medullary nailing: interference with cortical circulation of the canine tibia. Arch Orthop Trauma Surg 1990;109:314-6. 2. Sargeant ID, Lovell M, Casserley H, Green AD. The AO unreamed tibial nail: a 14-month follow-up of the 1992 TT experience. Injury 1994;25:423-5.