Introduction

Diaphyseal tibial fractures account for approximately 1.9% of adult fractures. Studies have demonstrated a high proportion have ipsilateral occult posterior malleolus fractures. We hypothesize that this rotational element will be highlighted using the Mason & Molloy Classification.

The purpose is to present our experiences with the conversion of external fixation to an intramedullary nail in the treatment of open fractures and fractures in polytraumatised patients. These are traumatological cases where primary use of an intramedullary nail is difficult or impossible.

References in the world literature to the two-stage treatment of the fractures of the tibial shaft are more than 2O years old and are considered as unsuccessful. However, later papers presented conversion as an advantageous procedure. A higher stability of the fracture and better comfort of the patient are acquired by the use of conversion.

From 1995 to 1999 in the Orthopedic Clinic Bulovka in Prague, Czech Republic, ten patients (8 male, 2 female) were treated by the method of conversion of external fixation to an intramedullary nail. The group of patients was composed of eight open fractures: one Gustillo-Anderson 1, two Gustillo-Anderson 2, three Gustillo-Anderson 3A, two Gustillo-Anderson 3B, one closed fracture Tscherne CIII, and one closed fracture Tscherne CII in a polytraumatised patient. Conversion was performed from 6 to 48 days after primary stabilisation by external fixation (mean 21.2 days). We currently use the UNI-fix clamp external fixator. Conversion by standard procedure is performed up to the 21st day to the 28th day after primary stabilisation. Injury of soft tissues and skin covering must be solved at the time of conversion.

Analysis of the results in the ten cases was made from three months to 4.5 years. All of the cases were subjectively classified as excellent or very good. There were no deep infections. In three cases there was prolonged secretion from the screw holes of the external fixator. For one patient, bone grafting into a fracture bone defect was necessary after six months. ROM of the knee and ankle joint was without reduction of function. When the period of follow-up was more than one year, all patients had perfect healing of the fractures.

This method gives very satisfactory therapeutic results with a minimum of complications, and covers the spectrum of the treatment of complicated fractures of the tibial shaft. However, the indications are very strict. If conversion is not able to be performed before the 21st to the 28th day after primary stabilisation, it is more advantageous to continue with treatment by external fixation because of the risk of deep infection. After the 28th day following primary stabilisation, conversion to an intramedullary nail is not indicated.

Purpose: The evaluation of the results of intramedullary nailing of open fractures of tibial shaft, which have been initially treated with external fixation.

Material & Method: Between 1997–2003, in 58 open fractures of tibial shaft (Gustillo type II & IIIa), the initially applied external fixation was replaced by an intramedullary nail type Russell-Taylor or Grosse-Kempf, either due to delay in union progress or due to frame‘s loosening. The conversion of external fixation to intramedullary nail was performed between 12th–15th week (average: 14th week), in two stages (1st stage: removal of EX.FIX, 2nd stage: insertion of I..N); with 13–22 days interval between the stages. In all cases, no elements of infection were noticed. In 45% of the patients bone grafting was performed at the time of nail‘s insertion. 37 patients were men and 21 were women, aged 19–52 years old (average: 31,7yrs). All patients were treated by the same surgical team and followed-up routinely.

Results: Union was achieved in 85% of the fractures, usually between 16–23 weeks (average: 18,7 weeks) from nail‘s insertion. In 7 cases, another operation was needed. Bone grafting in five, exchange of nail in two. Neither infection nor DVT was noticed. 82% of patients started sociallizing within 4 weeks, while 79% returned to pre-injury activities.

Conclusions: In cases that the union progress of the externally fixed open fractures of tibial shaft is not satisfactory; the conversion of external fixation to intramedullary nail seems to be a reliable option. The key points for the success of the method are timing and conditions of that conversion.