Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 6  |  Issue : 4  |  Page : 383-389  

Comparative study between reamed versus unreamed interlocking intramedullary nailing in compound fractures of shaft tibia


Department of Orthopedics, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India

Date of Web Publication17-Sep-2013

Correspondence Address:
Subhash Puri
Department of Orthopaedics, Padmashree Dr. D.Y. Patil Medical College, Pimpri, Pune - 411 018
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.118280

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  Abstract 

Background: Tibia is the commonest bones to sustain open injury because of subcutaneous position. Treatment of open fractures requires simultaneous management of both skeletal and soft tissue injury. Intramedullary nailing with reaming is generally considered to be contraindicated for open fractures tibia, because it damages the endosteal blood supply which will lead to non-union, deep infection. However, recent studies with or without reaming in open fracture tibia shows no influence in healing of fracture. Purpose: To compare the clinical and radiological results of intramedullary interlocking nailing of open fractures of the tibial shaft after reaming versus unreamed medullary canal. Materials and Methods: Between 2008 and 2011, we have treated 40 patients with compound tibia fracture (type I, II, IIIA) by simultaneous care of wound and skeletal injury. Primary fixation for fracture stabilization was done by closed intramedullary interlock nailing either reamed or unreamed; the allocation to the two groups made on alternating basis. Wound was managed by thorough debridement with primary/delayed primary closure by suturing, split thickness skin grafting or fasciocutaneous flap cover. Active, non-weight bearing exercises were started from next post-op day. Partial weight bearing after suture removal was started on 12 th day. Further follow-up was done at 6 weeks interval for union. Results: Open fractures of shaft of tibia treated with unreamed/reamed interlocking nailing gave excellent results. In present series, 19 fractures (95%) treated by unreamed and 19 (95%) fractures treated by reamed technique, united within 6 months of injury. Delay in union was noticed in one patient treated by unreamed technique who had segmental and extensive soft tissue injury and in reamed nailing there was one patient with deep infection, which was treated with antibiotic coated nail. Conclusion: Time to complete union was similar in both groups. Adequate debridement of wound and adequate soft tissue coverage is the key to minimize deep infection irrespective of whether the bone is reamed or not.

Keywords: Open tibial fractures, primary fracture fixation, primary soft tissue coverage, reamed/unreamed intramedullary interlocking nailing


How to cite this article:
Puri S, Biswas SK, Salgia A, Sanghi S, Agarwal T, Malhotra R. Comparative study between reamed versus unreamed interlocking intramedullary nailing in compound fractures of shaft tibia. Med J DY Patil Univ 2013;6:383-9

How to cite this URL:
Puri S, Biswas SK, Salgia A, Sanghi S, Agarwal T, Malhotra R. Comparative study between reamed versus unreamed interlocking intramedullary nailing in compound fractures of shaft tibia. Med J DY Patil Univ [serial online] 2013 [cited 2024 Mar 29];6:383-9. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2013/6/4/383/118280


  Introduction Top


With increasing number of vehicles on the roads in India, complex trauma cases caused by traffic accidents have increased progressively. Tibia is one of the most common bones to sustain open injury because of subcutaneous position. Indirect injuries are usually low energy and direct injury is usually high energy. The treatment of open fractures requires simultaneous management of both skeletal and soft tissue injury. After stable fixation, damage to the surrounding tissue is decreased and soft tissue care is facilitated. [1] The option of skeletal stabilization method for open fractures of the tibial shaft continues to be debatable. Treatment options include cast immobilization, open reduction and internal fixation with plates, external fixator and intramedullary nailing. [2] The goals for the successful outcome of treatment of open fracture of tibia include prevention of infection, the achievement of bony union and the restoration of function. These goals are interdependent and usually are achieved in chronological order. [3] Immobilization in a plaster cast, fixation with plates and screws has yielded unacceptably high rates of infection. External fixation considered to be treatment of choice by many traumatologists has the disadvantages of bulky frames and frequent pin tract infections having non-unions and malunions. [4] Intramedullary nails such as Ender nails, without reaming having low rates of postoperative infection are however, unsuitable for comminuted fractures as there is tendency for shortening or displacement of such fractures around these small nails. [4] The locking of intramedullary nails of the major proximal and distal fragments decreases the risk of malunion. Intramedullary nailing with reaming of the medullary canal is generally considered to cause the damage to the endosteal blood supply, which may thereby increase the risks of deep infection and non-union. It has, therefore, been suggested that insertion of nails without reaming is safer. Recent studies have indicated, however, that nailing either with or without reaming can be used for open tibial fractures with equal results of union in either method.


  Aims and Objectives Top


To assess the clinical and radiological outcome of unreamed versus reamed intramedullary interlocking nailing in open tibial shaft fracture and to compare functional outcome and results in the patients.


  Material and Methods Top


Forty patients with open tibial fracture were treated with reamed or unreamed interlock nailing; the patients being allocated to the two groups alternatively. Inclusion Criteria: Men and women more than 18 yrs with open tibial shaft fractures (Gustilo Anderson type I, II, IIIA). Inclusion required informed consent. Exclusion Criteria: Patients with fractures that were not amenable to either reamed or unreamed techniques, those with pathological fractures and those where follow-up was difficult. Patients were divided into two groups consisting of 20 patients in each group. Group A patients were operated using closed intramedullary interlocking without reaming and group B with reaming for fracture stabilization. A thorough clinical examination was performed including detail history relating to age, sex, occupation, mode of injury, past and associated medical illness. A sterile dressing was applied to open wound and the limb immobilized in pop slab or Thomas splint. Further wound care in Gustilo Anderson type I/II through debridement and primary closure/delayed primary closure/skin grafting was done in most of the cases. For type IIIA, stabilization of fracture was done by intramedullary reamed/unreamed interlocking nail. Wound cover was done primarily after debridement by suturing/fasciocutaneous/fasciomyocutaneous flap cover in patient who reaches within first 6 hours; if patient reaches after 6 hours, the wound was left open after debridement followed by daily sterile dressing till wound became clean and healthy for delayed primary closure by split thickness skin graft/fasciocutaneous/ fasciomyocutaneous flap. Active knee, ankle and toe movements were started immediately and non-weight bearing exercises on next post-operative day. Sutures were removed on the 10 th -12 th postoperative day. Partial weight bearing with crutch walking/walker commenced after the 12 th day. Further follow-up is done at 6 weekly intervals to assess union clinically and radiologically.

Pre-operatively, the length of the nail was calculated by tibial tubercle-medial malleolar distance (TMD) [5] and diameter of the nail was assessed by measuring tibial marrow cavity at narrowest point or isthmus.


  Surgical Technique Top


In the reamed nailing group, intramedullary reaming was conducted over a guide wire with the use of cannulated reamers. All surgeons adhered to the same protocol. First, the surgeon reamed the intramedullary canal until the first detection of "cortical chatter", forming the basis for the nail diameter. Following the appearance of "cortical chatter", the surgeon reamed 1 to 1.5 mm larger than the chosen nail's diameter.

In the unreamed nailing group, the surgeon inserted the nail, without reaming, across the fracture site, with particular attention being paid to the prevention of over distraction and the achievement of cortical contact of the fracture ends. An upper diameter limit of 10 mm and a nail measuring at least 2 mm less than the diameter measured at the isthmus of the tibia on anteroposterior and lateral radiographs were stipulated.

In both groups, the study required interlocking of all nails with at least one proximal locking screw and one distal locking screw.

Post-operative Management

All the cases were given cephalosporin and aminoglycoside and were continued for 5 days postoperatively after which patient was switched over to oral antibiotics. Analgesics if required were given. Depending upon the culture report of the wound and its condition, antibiotics are continued. Partial weight bearing crutch walking/walker commenced after 12 days, depending upon the type of fracture, rigidity of the fixation and the type of the nail used and associated injuries. Further follow-up is done at 6, 12 and 24 weeks and each patient is individually assessed clinically and radiologically ([Figure 1] and [Figure 2] in unreamed and [Figure 3] and [Figure 4] in reamed).
Figure 1: Unreamed patient pre-op, post-op, follow-up.

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Figure 2: Functional range of movements at 24 weeks follow-up, wound healed up and no muscle atrophy in unreamed patient

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Figure 3: Reamed patient pre-op, post-op, follow-up

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Figure 4: Functional range of movements at 24 weeks follow-up, wound healed up and no muscle atrophy in reamed patient

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Union was defined by the presence of bridging callus on two radiographic views and the ability of patients to bear full weight on the injured extremity if other injuries allowed.

Functional outcome was evaluated on the basis of the following criteria by Klemm and Borner, 1986. [6] Excellent: Full knee and ankle motion, no muscle atrophy, normal radiographic alignment. Good: Slight loss of knee and ankle motion (<25°), less than 20 mm of muscle atrophy, angular deformity (5°). Fair: Moderate (25°) loss of knee or ankle motion, more than 2 cm of muscle atrophy, angular deformities (5-10°). Poor: Marked loss of knee or ankle motion (25°), marked muscle atrophy, angular deformities (>10°).

All patients were mobilized by active knee bending, and quadriceps exercises were initiated after recovering from anesthesia.

Malunion is defined as angulation in coronal plane (varus-valgus) of >5%, sagittal plane (anterior-posterior) angulation >10% or >1 cm of shortening.


  Results Top


Age Distribution of the Patients

This is shown in [Table 1]. The mean age in the unreamed group was 36.6 years with standard deviation (SD) of 13.53 years while in the reamed group the mean age was 32.75 years with SD of 8.29 years. The difference in age was not statistically significant.
Table 1: Age distribution in reamed and unreamed group


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Gender Distribution of the Study Population

In the unreamed group, 17 patients (85%) were males, while in the reamed grouped 19 patients (95%) were males. The gender difference in the two groups was not statistically significant (Fisher exact two tailed test P = 0.6).

Mode of Injury

This is shown in [Table 2]. The major cause of injury in both the groups was vehicular accidents particularly motorcycle followed by pedestrian injury. Only 1 case (in the reamed group) was due to assault. Majority of the fractures were sustained on the right side (80% in the unreamed group and 65% in the reamed group).
Table 2: Mode of injury in reamed and unreamed g


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Type of Fracture

In the unreamed group, majority of open fracture of tibia were Gustilo type II (50%), type I (40%) and type IIIA (10%). The predominant tibial fracture pattern was oblique 35%. The predominant were middle third, distal third 50% and comminuted (15%). In group B, majority of open fracture of tibia were Gustilo type I (50%), type II (40%) and type IIIA (10%). The predominant tibial fracture pattern was oblique 40% [Table 6]. The predominant were middle third 55% and comminuted (5%) [Table 3] and [Table 4].
Table 3: Gustilo-Anderson grade of fracture in reamed and unreamed group


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Table 4: Pattern of fracture in reamed and unreamed group


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Time Between Trauma and Operation

Most of the patients (40%) in our study in group A were operated 2-4 days after trauma, 6 cases (30%) were operated less than 8 hours of trauma and in group B, majority of patients (45%) were operated 2-4 days after trauma and 4 cases (20%) were operated less than 8 hours of trauma [Table 5]. In all cases mid-line patellar tendon splitting approach was used for nail insertion.
Table 5: Duration between trauma and operation in reamed and unreamed group


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Weeks taken for Union to Occur and Incidence of Infection in the Groups

In unreamed cases, 19 (95%) of 20 fractures united between 3 and 8 months and among these 15 fractures healed before 20 weeks (75%) and 4 fractures united between 21 and 30 weeks (20%). One fracture with communition of Gustilo type II failed to unite 6 months after surgery. Patient was operated with exchange nailing with reaming with bone grafting and fibulectomy. In group B, 19 (95%) of the 20 fractures united. The time to union ranged from 3 to 8 months in reamed cases, among these 16 fractures healed before 20 weeks (80%) and 3 fractures united between 21 and 30 weeks (15%). One fracture with communition of Gustilo type IIIa failed to unite due to deep infection, 6 months after injury. This patient was operated with external fixator [Table 6] and [Table 7].
Table 6: Union in cases of reamed and unreamed nailing


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Table 7: Infection in reamed and unreamed group


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Range of Motion at Knee and Ankle Joints in the Two Groups

In unreamed group, 18 patients had full range of knee motion at 12 weeks (90%) and more than 25% loss of knee motion in two cases (10%), 17 patients had full range of ankle motion at 12 weeks (85%), 2 cases had less than 25% ROM of ankle and 1 patient had more than 25% loss of ROM of ankle. In group B, 17 patients had full range of knee motion at 12 weeks (85%), 3 cases had less than 25% ROM of knee (15%). Sixteen patients had full range of ankle motion at 12 weeks (80%), 2 cases had less than 25% ROM of ankle (15%) and 1 patient had more than 25% loss of ROM of ankle [Table 8].
Table 8: Range of motion of knee and ankle in reamed and unreamed group


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In unreamed group, no malunion was noted. In reamed group, one case of valgus angulation was noted less than 10% of angulation. No shortening was noted in either group.

Complications

In unreamed group, one patient of Gustilo type II developed superficial infection; it was controlled by oral antibiotics. One patient of Gustilo type II developed deep infection and was treated with intravenous antibiotics; in this case fracture did not unite at the end of 9 months of trauma. In reamed group, two patients of Gustilo types I and II developed superficial infection; it was controlled by oral antibiotics. One patient of Gustilo type II developed deep infection and was treated with intravenous antibiotics; in this case fracture did not unite at the end of 9 months of trauma.

Functional Outcome

Functional outcome in unreamed group was as follows: 15 cases had excellent results, 4 cases good results and 1 case had poor results. In reamed group, 15 cases had excellent results, 4 had good results and 1 had poor results.


  Discussion Top


The management of open tibial shaft fractures continues to be a problem with several unanswered questions. Those fractures, usually caused by high energy trauma, having numerous problems resulting from the poor soft tissue coverage and limited vascular supply of the tibia, cause malunion, non-union, infection and sometimes resulting in amputation. Recent improvements in wound coverage techniques and fixation devices have decreased the prevalence of these complications, but the optimum management of open fractures of the tibial shaft is evolving. [4]

These cases are of different age groups that occurred in both sexes and the fracture were of different types and at different levels. Majority of patients in our study was between 28 and 37 years. In a study of 94 open fractures of tibia conducted by Keating et al., [7] average age was 37 years. In another study of 137 open fracture of tibia by Blachut et al., [8] average age was 36 years. Majority of cases sustained fractures from road traffic accidents in our study. Same phenomenon has also been reported by others. [7],[8]

There are two major factors related to the final outcome in tibial shaft fractures: The first is the severity of the fracture, characterized according to Nicoll [9] by the degree of initial displacement, communition and soft tissue injury. The second factor is the damage of the tibial blood supply. In open fractures, not only is the endosteal circulation disrupted but also is the periosteal circulation, after severe soft tissue damage and periosteal stripping from the bone.

Application of a plaster cast has been most common method of treatment for open fractures of the tibia, but it has several disadvantages. Nicoll [9] reported rate of infection of 15% after the treatment of 140 open tibial fractures with a cast. Brown and Urban [10] reported that 27% of 63 open fractures of the tibial shaft have healed with more than 10 mm of shortening and 6.3% with more than 30 mm of shortening. More recently, Puno [11] et al. reported a 12.5% rate of malunion in a series of 24 open tibial fractures treated with cast. Immobilization in a plaster cast, therefore, should be reserved for stable fractures with minimum soft tissue injury.

In plate osteosynthesis, Smith [12] studied 219 open fractures treated by internal fixation on the day of injury, delayed union occurred in 48% and infection in 20%. Johner and Wruhs [13] reported non-union was twice as common and infection five times more likely when open fractures were treated with plating.

The success of locking nails for the treatment of closed tibial fractures has stimulated interest in their use for open tibial fractures. Intramedullary nailing after reaming is now accepted as the method of choice to treat open fractures, but its use remains controversial with regard to open tibial fractures. The vascular damage inflicted by reaming in association with the soft tissue injury has been thought to increase the risk of infection and delayed union to an unacceptable level. Early reports of the use of unlocked nails with reaming for open tibial fractures seems to confirm this view. [7]

Smith [15] found a rate of infection of 33% in series of 18 open tibial fractures treated with intramedullary nailing with reaming, most of the fractures were associated with severe soft tissue injury. Some traumatologists believe that intramedullary nailing with reaming may be used safely for fracture with less severe wounds. Kelmm and Borner [6] reported 6 infections developed after the use of treatment of 93 grade I open fractures with insertion of interlocking intramedullary nailing after reaming. Bone and Johnson [15] reported two infections after treatment of grade II and grade III with nailing after reaming. On the basis of these studies, the current opinion of insertion of nail after reaming is contraindicated for open tibial fractures. The criticism that nailing after reaming is associated with high rates of infection and non-union is theoretical and is based on limited reports with small numbers of patients managed mostly with unlocked nails. Kaltenecker et al. [16] reported no infections after treatment of 66 types I and II open tibial fractures with nailing after reaming.

In the current series, 40 cases of open fractures of shaft of tibia were treated with reamed and unreamed interlock nailing over a period of 2 years. They were followed up for an average of 6-8 months. The purpose of this was to evaluate the end results of treatment of these patients.

In reported studies as well as in present study, the open fractures of shaft of tibia treated in unreamed and reamed interlocking nailing gave excellent results. In the present series, 19 fractures (95%) treated by unreamed and 19 (95%) fractures treated by reamed, united within 6 months of injury, and in a study by Blachut et al. [8] [Table 9], 56 fractures treated by unreamed and 70 fractures treated with reamed nailing united within 8 months of injury. In the present study [Table 9], there was one deep infection in each group (5%) of Gustilo type II open fracture, in Keating et al. [Table 9] study, one fracture in the group without reaming who had Gustilo type II fracture and 2 fractures in group treated with reaming developed injection. Malunion was defined as angulation in varus-varus >5%, anterior-posterior angulation >10% or >1 cm of shortening. In present study, one case of reamed had malunion. The incidence of malunion Keating [7] study was 2% in unreamed patients and 4% in reamed patients; in Balchut et al [8] study, 2 fractures in the group that had nailing without reaming and 3 fractures that had nailing with reamed had malunion.
Table 9: Comparison of Keating et al,[7] Blanchet et al[8] and our study


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In present study in patients treated with unreamed method, in 18 patients, the full range of knee motion was 90% and in group 2, in 17 patients, the full range of knee motion was 85% and at the end of study functional outcome of each was done with group A in which 15 cases had excellent results, 4 cases good results and 1 case had poor results. In reamed group, 15 cases had excellent results, 4 cases good results and 1 case had poor results. In studies by Keating et al and Blachut et al., the functional outcome was similar in patients of unreamed and reamed. In present study, there were no nail failure or screw breakages in cases of reamed and unreamed. In Blachut et al [8] study, 1.4% had nail failure and 2.7% had screw breakage in patients of reamed and 16% had screw breakage and there were no nail failure in patients of unreamed. In Keating et al [7] study, 4.3% patients had nail failure and 9% had screw breakage in patients of reamed and 29% had screw breakage and nail failure in 2.4% patients of unreamed was reported [Table 9].


  Conclusion Top


Clinical and radiographic results of nailing after reaming are similar to those of nailing without reaming for fixation of open fractures of the tibial shaft. The over-all time to union was similar between the two groups, with no evidence that the reaming process delays union. Operative care of the soft tissue wound is critical in the treatment of open fractures. On pluripotential mesenchymal cells that form fibrous tissue and cambium layer of the periosteum, the reaming process is likely to have little detrimental effect on this aspect of fracture healing. The role of the endosteal circulation in fracture healing therefore is less critical than has been supposed. Adequate debridement of the soft tissue and bone followed by adequate soft tissue coverage is the key to minimize deep infection after these injuries, irrespective of whether the bone is reamed or not, which is the outcome of present study.

 
  References Top

1.Olson SA. Open fractures of the tibial shaft. Current instructional course lectures. the american academy of orthopedic. J Bone Joint Surg 1996;78:1428-37.  Back to cited text no. 1
    
2.Hooper GJ, Keddell RG, Penny ID. Conservative management or closed nailing for tibial shaft fractures shaft a randomized prospective trial. J Bone Joint Surg 1991;73:83-5  Back to cited text no. 2
    
3.Templeman DC, Gulli B, Tsukayama DT, Gustilo RB. Update on the management of open fracture of the tibial shaft. Clin Orthop Relat Res 1998;350:18-25.  Back to cited text no. 3
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4.Whittle AP, Russell TA, Taylor JC. Lavelle DG. Treatment of open fracture of tibial shaft of open fractures of the tibial shaft with the use of interlocking nailing without reaming. J Bone Joint Surg Am 1992;74A:1162-71.  Back to cited text no. 4
    
5.Whittle AP. Fracture of lower extremity". Chapter-47 in "Campbell's operative orthopaedics. 9 th ed. New York: Mosby; 1998. p. 2067-94.  Back to cited text no. 5
    
6.Klemm KW, Börner M. Interlocking nailing of complex fractures of the femur and tibia. Clin Orthop Relat Res 1986;212:89-100.  Back to cited text no. 6
    
7.Keating JF, O'Brien PJ, Blachut PA, Meek RN, Broekhuyse HM. Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am 1997;79:334-41.  Back to cited text no. 7
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8.Blachut PA, O'Brien PJ, Meek RN, Broekhuyse HM. Interlocking intramedullary nailing with and without reaming for the treatment of open fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg 1997;79-A:640-6.  Back to cited text no. 8
    
9.Nicoll EA. Fractures of the tibial shaft: A survey of 705 cases. J Bone Joint Surg 1964;46B:373-87.  Back to cited text no. 9
    
10.Brown PW. Urban JG. Early weight bearing treatment of open fracture of the tibia: An end result of 63 cases. J Bone Joint Surg Am 1969;51-A:59-75.  Back to cited text no. 10
    
11.Puno RM, Teynor JT, Nagano J, Gustilo RB Critical analysis of results of treatment of 201 tibial shaft fractures. Clinc Orthop 1986;212:113-21.  Back to cited text no. 11
    
12.Smith JE. Results of early and delayed internal fixation for tibial shaft fractures: A review of 470 fractures. J Bone Joint Surg Br 1974;56-B:469-77.  Back to cited text no. 12
    
13.Johner R, Wruhs O. Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop 1983;178:7-25.  Back to cited text no. 13
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14.Holbrook JL, Swiontkowski MF, Sanders R. Treatment of open fracture of the tibial shaft: Ender nailing versus external fixation: A randomized prospective comparision. J Bone Joint Surg 1989;71:1231-8.  Back to cited text no. 14
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15.Bone LB, Johnson KD. Treatment of tibial fractures by reaming and intramedullary nailing. J Bone Joint Surg Am 1986;68:877-87.  Back to cited text no. 15
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16.Kaltenecker G, Wruhs O, Quaicoe S. Lower infection rate after interlocking nailing in open fractures of femur and tibia. J Trauma 1990;30:474-9.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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Abstract
Introduction
Aims and Objectives
Material and Methods
Surgical Technique
Results
Discussion
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