DIFFERENTIATED INDICATION FOR INTRAMEDULLARY NAILING OF TIBIAL FRACTURES - REAMED VERSUS UNREAMED TECHNIQUE

The principle of unreamed intramedullary nailing in tibial fractures is theoretically convicing: regarding the almost fully maintained endosteal blood supply, this concept of biological osteosynthesis implies a lower rate of postoperative complications such as non- or malunion and infection. In our clinic, 89 patients underwent intramedullary nailing of the tibia since August 1988 using the ''AO-Universal-Nagel'' in 63 and the Russell-Taylor unreamed nail in 26 cases. With primary data (type of fracture and grade of soft tissue injury) being comparable, we found an almost identical rate of infection for both techniques. In RT nailing, however, rates were significantly higher for non- or malunion (AO 10,3%, RT 27,6%) and implant complications such as interlocking screw or nail breakage (AO 6,2%, RT 17,2%). Thus indicating less mechanical stability, for RT- nail we allowed full weight bearing after 6-8 weeks only, whereas for AO-nail this was performed approximately 14 days p. op. after satisfying soft tissue conditions had occured. Subsequently, this worse mechanical properties of an unreamed nail mean loss of comfort for patients, which is not fully equalized by biological advantages in all cases. We therefore champion a differentiated indication for the unreamed technique, determined by the grade of soft tissue injury: treatment of Gustilo type II and III a and b open tibial fractures by eithe primarily performing biological osteosynthesis or early changing from external fixation. Finally, unreamed nailing has been established as monorail procedure treating defect fractures by means of segmental transport.