• C Gaebler, U Berger, P Schandelmaier, M Greitbauer, H H Schauwecker, B Applegate, G Zych, and V Vécsei.
• Department of Traumatology, University of Vienna Medical School, Vienna, Austria.
• J Orthop Trauma. 2001 Aug 1;15(6):415-23.

ObjectiveA multicenter trial analyzed complications and odds for complications in open and closed tibial fractures stabilized by small diameter nails.DesignRetrospective.SettingFour Level I trauma centers.PatientsFour hundred sixty-seven tibial fractures were included in the study. There were fifty-two proximal fractures, 219 midshaft fractures, and 196 distal fractures. Breakdown into different AO/OTA groups showed 135 Type A fractures, 216 Type B fractures, and 116 Type C fractures. Two hundred sixty-five were closed fractures and 202 were open fractures.Outcome MeasurementsClinical and radiographic analysis.Methods467 patients' tibial fractures were stabilized with small diameter tibial nails using an unreamed technique. Indications for the use of small diameter tibial nails using an unreamed technique included all types of open or closed diaphyseal fractures. The operating surgeons decided whether or not to ream based on personal experience, fracture type, and soft-tissue damage. Surgeons of Center 1 preferred to treat AO Type A and B fractures with unreamed nails, and surgeons of Centers 2, 3, and 4 preferred to treat AO Type B and C fractures with unreamed nails. Closed and open fractures were treated in approximately the same ratio.ResultsAnalysis showed five (1.1 percent) deep infections (with a 5.4 percent rate of deep infections in Gustilo Grade III open fractures), forty-three delayed unions (9.2 percent), and twelve (2.6 percent) nonunions. Compartment syndromes occurred in sixty-two cases (13.3 percent), screw fatigue in forty-seven cases (10 percent), and fatigue failure of the tibial nail in three cases (0.6 percent).ConclusionsFracture distraction of more than three millimeters should not be tolerated when stabilizing tibial fractures with unreamed, small-diameter nails as this increases the odds of having a delayed union by twelve times (p < 0.001) and a nonunion by four times (p = 0.057). There was a significant increase of complications in the group of Grade III open fractures (p < 0.001), AO/OTA Type C fractures (p = 0.002), and to a lesser extent in distal fractures. However, the rate of severe complications resulting in major morbidity was low.

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