Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 22  |  Issue : 2  |  Page : 115-121

Open intramedullary nailing using ‘Greens Instrumentation’ in the treatment of femoral and tibial shaft fractures: a 5 years review of cases in a private health facility in the Niger Delta region of Nigeria


Department of Surgery, Delta State University, Abraka, Nigeria

Date of Submission15-Mar-2020
Date of Decision28-Apr-2020
Date of Acceptance04-Jun-2020
Date of Web Publication11-Sep-2020

Correspondence Address:
Dr. David O Odatuwa-Omagbemi
Department of Surgery, Delta State University, Abraka
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomt.jomt_7_20

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  Abstract 


Background: Open reduction and intramedullary locked nailing using external jig (usually without intra-operative imaging) is gaining widespread popularity in developing and resource-poor countries for the management of lower limb long bone shaft fractures. I share our experience using the “Greens” instrumentation in the treatment of femoral and tibial shaft fractures in a private health facility in Delta State, Nigeria. Methods: This was a retrospective review of patients who had lower limb long bone shaft fractures seen and treated with open intramedullary nailing at a private health facility in Warri, Delta state Nigeria, over a five year period. Results: There were 20 patients with 21 lower limb long bone shaft fractures made of 13 males and 7 females (M:F = 1.5:1). Average age of patients was 42±18 years. Fifty per cent of the fractures were caused by RTA. The femur was affected in 19 fractures (90.5%) and 2 fractures affected the tibia (9.5%). Three of the fractures were open. Sixteen patients presented fresh (within 2 weeks of fracture) while the rest 4 presented at an average of 7.8±1.5 months post fracture with various complications after treatment elsewhere. All patients except 1 had open nailing. Average length of hospital stay was 19.0±9.3 days. The average time between surgery and partial weight bearing was 10.0±6.7 weeks while mean time to full weight bearing was 18.5± 6.7 weeks. Complications included deep infections in 2 patients, distal screw displacement due to early weight (against instruction) in 1 patient, delayed union in 1 patient and death of 3 patients. Conclusion: Open IM nailing of femoral and tibial shaft fractures with the “Greens” instrumentation is an effective treatment method in resource-poor settings like ours where intra-operative imaging is not readily available.

Keywords: External Jigs, intramedullary Nailing, lower limbs long bone shaft fractures, open reduction


How to cite this article:
Odatuwa-Omagbemi DO. Open intramedullary nailing using ‘Greens Instrumentation’ in the treatment of femoral and tibial shaft fractures: a 5 years review of cases in a private health facility in the Niger Delta region of Nigeria. J Med Trop 2020;22:115-21

How to cite this URL:
Odatuwa-Omagbemi DO. Open intramedullary nailing using ‘Greens Instrumentation’ in the treatment of femoral and tibial shaft fractures: a 5 years review of cases in a private health facility in the Niger Delta region of Nigeria. J Med Trop [serial online] 2020 [cited 2020 Sep 20];22:115-21. Available from: http://www.jmedtropics.org/text.asp?2020/22/2/115/294823




  Introduction Top


Long bone shaft fractures of the lower extremities are becoming increasingly common clinical presentations of trauma patients to the emergency units of many hospitals in Nigeria.[1] Several methods of treatment of these fractures have been used over the years including use of tractions, casts/cast bracing, external fixation, internal fixations with plates and screws, intramedullary nailing etc. Non locking intramedullary nailing was first introduced by Kuntscher.[2],[3] Locked intramedullary nailing has now become the gold standard in the treatment of these shaft fractures as it provides both axial and rotational stability in addition to early weight bearing by patients and has thus gained wide acceptance internationally including in Nigeria.[3],[4],[5] Results from clinical experiences with the use of locked intramedullary nails for lower limb long bone shaft factures in centres in Nigeria are comparable with published results from other treatment centres internationally.[1],[3],[6],[7],[8]

Closed intramedullary nailing with intraoperative fluoroscopy for reduction and placement of locking screws on a fracture table is the standard procedure internationally. However this closed method is not yet in widespread use in Nigeria and other resource-poor nations due to the fact that C-arm and fracture table required for effective closed reduction and placement of distal locking screws are not readily available in many hospitals here due to cost.[1],[6],[7],[8],[9]

Intramedullary nailing using open reduction of fractures and external jigs for placement of locking screws is a more popular method in Nigeria and other resource-poor settings as it does not require costly equipment like C-arm and fracture table and the instruments and implants are cheap and more easily affordable. Results of fracture healing rate using the open method have been quite encouraging and not too different from that reported using the closed method of nailing.[1],[3],[6],[7],[8] The Surgical Instruments Generation network (SIGN) instrumentation/implants have been used in several centres in Nigeria and some African countries with reports of good results in the literature.[6],[7],[8],[9],[10],[11]

Other instrumentations/implants using similar principle of open reduction and external jigs for placement of locking screws are also being used in Nigeria and other resource-poor settings where intra-operative fluoroscopy and fracture tables are not readily available due to cost. The aim of this study was to share our clinical experience using the “GREENS INSTRUMENTATION − India” for open reduction and locked intramedullary nailing of femoral and tibial shaft fractures in a private health facility in Warri, Nigeria.


  Materials and methods Top


Cases of femoral and tibial shaft fractures treated with intramedullary nailing using the “GREENS” instrumentation over a period of 5 years (January 2014–December 2018) in a private health facility in Warri, Nigeria were included in this study.

The “GREENS” intramedullary nail instrumentation was meant to be used with or without intra-operative imaging. It has separate external jigs for the placement of both proximal and distal locking screws when nailing femoral and tibial shaft fractures. It becomes very useful in our environment where C-arm and fracture tables are not readily available due to scarcity of resources.

Theatre and ward records of patients who had treatment of femoral and tibial shaft fractures with the GREENS instrumentation were retrieved and relevant information on biodata, aetiology of fractures, time of presentation post-injury, previous treatment, peri-operative and post-operative problems, time to partial and full weight bearing, etc., were extracted and entered into a proforma designed for that purpose. Patients who had incomplete records were excluded. Data were analysed using SPSS version 18 and presented in form of ratios, means, percentages and table.

Procedure

The GREENS instrumentation for intramedullary nailing has separate external jigs used to place locking screws in the femur and tibia without need for fluoroscopy. There are different hollow nails for the tibia and femur which are of varying sizes (lengths and diameters) [Figure 1]. The nails have two holes proximally (1st oval and the 2nd round) and two round holes distally.
Figure 1: Tibial nail (left) and femoral nail (right).

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For femoral shaft fractures, patient under anaesthesia was placed in a lateral position with the affected limb uppermost and the normal limb flexed at both the hip and the knee. Sandbags were used to maintain position. Peri-operative antibiotic was given. The fracture site was exposed minimally via a lateral thigh incision, the fracture fragments were held and reamed with solid Kuntscher type rigid reamers at 1mm intervals beginning usually from the smallest size (8 mm) and starting with the proximal fragment to a size about 1mm greater than the desired diameter. The length of nail used was estimated before operation by measuring from the greater trochanter to the upper pole of the patellar in the normal limb and subtracting 2 cm from the value gotten and intra-operation by using a guide wire to sound both fragments after reaming. A small-sized reamer was then used to create a hole in the piriformis fossa in a retrograde manner through the medullary canal. A fresh incision was made over the greater trochanter and deepened to expose it. A guide wire was then passed from the fracture site into the medullary canal of the proximal fracture fragment to come out through the hole created in the piriformis fossa at the proximal incision made over the greater trochanter. The desired nail was mounted on the appropriate jig [Figure 2] and threaded over the guide wire through the piriformis fossa into the medullary canal of the proximal fragment until it gets to the fracture site and the guide wire was then removed. The bone fragment ends were held with bone clamps, the fracture reduced and nail advanced through the fracture site into the medullary canal of the distal fragment until just about 5 to 10 mm of nail is protruding out at the piriformis fossa. Using the external jig as guide, locking screws were then placed proximally and distally [Figure 4] (number of screws vary from 2 to 4). If fluoroscopy were available, it was used to crosscheck screw positions and necessary adjustments made at this stage. The jig was then disengaged from the nail, wounds irrigated with normal saline and closed in layers.
Figure 2: Femoral nail mounted on the external jig or targeting device.

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For tibial shaft fractures, the patient under anaesthesia lies supine, the ipsilateral knee was flexed to about 700 to 900 with a support under the knee. The fracture site was minimally exposed via a longitudinal leg incision over it. A separate longitudinal incision was then made over the patellar tendon and proximal tibia to expose the entry point by splitting the patellar tendon. The appropriate bone awl [Figure 3] was used to create a canal by entering through the proximal end of the tibila just proximal to the tubercle with the awl directed postero-inferiorly to enter the medullary canal. Reaming was done through this entry point from proximal to distal to the desired size for the proximal fracture fragment using rigid Kuntscher type reamers. The distal fragment was reamed through the fracture site. The nail was mounted on the tibial external jig, a guide wire was passed through the proximal tibial entry point to the fracture site and the nail was advance over it to the fracture site. The guide wire was then removed, the fracture was reduced and the nail further advanced into the medullary canal of the distal fragment to the desired level. The calibrated arm of the external jig was used to guide placement of the locking screws as described for the femur but with the screws directed from medial to lateral cortices. The external jig was dismantled and wounds were irrigated and closed.
Figure 3: Bone awl for creating entry hole during IM nailing.

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All surgeries were done on a regular theatre table. For the last 5 cases C-arm was used to crosscheck position of screws when it became available and distal screws that missed the holes on 2 occasions were repositioned before dismantling the jig.

[Figure 4] and [Figure 5] are intra-operative photogragh and pre/post-operative radiographs respectively of a patient with mid-shaft femoral fracture who had locked intramedullary nailing done with the ‘Greens’ Intrumentation / nail.
Figure 4: Intra-operative process of placing a distal locking screw using the external jig.

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Figure 5: (A & B) Pre-op radiographs of patient with femoral shaft fracture; (C & D) post-op radiographs after open IM nailing.

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  Results Top


Twenty patients with 21 fractures were managed for femoral and tibial shaft fractures in our facility within the study period. There were 13 males and 7 females (M:F ∼ 1.5:1). The age of the patients ranged from 21 to 81 years with a mean of 42±18 years. [Table 1] shows age distribution and other socio-demographic characteristics of patients including aetiology of injuries. Twelve of the patients were married. Traders were the most commonly affected followed by retired persons. Road traffic accident was the commonest aetiology of the fractures. The femur was affected in 19 fractures (90.5%) and the tibia in 2 fractures (9.5%) in the same patient who suffered a pedestrian bumper injury. Eighteen of the fractures were closed while the rest three were open fractures.
Table 1: Sociodemographic characteristics of patients and aetiololy of injuries

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Associated injuries included: contralateral fibula fracture in one patient, Achille’s tendon injury in another patient and mandibular fracture in a third patient.

Sixteen patients (80%) presented with relatively fresh fractures with average time between injury and presentation of 2.8±2.3 days (range 1–10 days). The rest four patients presented with complications of previous treatment elsewhere at an average of 7.8±1.5 months post-injury (two non-unions from TBS treatment, one broken plate and screws and another bent IM Kuntscher nail). The mean time between injury and surgery in the early presenters was 7.6±4.3 days and for those that presented late was 8±1.5 months.

Open nailing was done in all cases except for the one patient that presented with a bent IM Kuntscher nail in which closed exchange nailing was done.

Intra-operative and post-operative issues included: (i) Anterior cortical perforation due to marrow sclerosis while reaming in a patient that had pathological fracture of the proximal femoral shaft from secondary deposit that originated from cancer of the prostate. (ii) Large cortical defects in two patients who had pathological femoral fractures from renal and prostate cancers respectively which had to be augmented with bone cement. (iii)One of the distal holes on three occasions were missed as shown on postoperative X-rays − however, fractures went on to heal without further intervention. (iv) Prolonged post-operative anaemia in a Jehovah’s witness patient that was managed with haematinics and erythropoietin. (v) Deep wound infection in two patients that were managed with local wound toileting/care and parenteral antibiotics. (vi) Early weight bearing 48 hours post-operation by a 21 year boy, drug addict who had IM nailing for bilateral tibial shaft fractures. He as a result had displacement of the distal screws on the left lower limb. He had manipulation and subsequent bilateral above knee cast application and went ahead to heal in 12 weeks with full weight bearing. (vii) Two patients died within 3 weeks of surgery from complications of co-morbid conditions (hypertension/ diabetes in one and prostate cancer in the 2nd patient). (viii) A third patient died of complications of renal cancer 18 months post surgery. He had pathologic fracture from a secondary bone deposit with a wide bone defect that was filled at surgery with bone cement and only progressed to partial weight bearing till death.

The average length of hospital stay for the patients was 19.0±9.3 days (range 8–46 days). The patient that stayed for 46 days was an elderly man, Jehovah witness with pathological femoral fracture from renal carcinoma and had to be managed for anaemia and other co-morbidities including haematuria.

Follow up was done every 4–6 weeks till union and full weight bearing. The average time between surgery and partial weight bearing was 10.0±6.7 weeks (range = 5 to 16 weeks).

The mean time between surgery and full weight bearing was 18.5±6.7 weeks. The case of bilateral tibial fractures achieved healing and full weight bearing 12 weeks post-op. One patient had delayed union and healed 80 weeks post-operation. He had dynamisation with bone grafting before progressing to heal.

Follow up for patients was for between 5 months and 4 years at 4–6 weeks intervals. At each clinical visit for follow up patients had X-rays done and were assessed for radiological and clinical union.


  Discussion Top


Locked intramedullary nailing for operative fixation of tibial and femoral shaft fractures has become the gold standard in the treatment of these fractures.[3],[12] The surgeries are done preferably with closed reduction, and locking where facilities like image intensifiers and fracture tables are available[13],[14],[15] or less preferably with open reduction and placement of locking screws using targeting external jigs.[1],[7],[8],[9] The later method is more popular in resource-poor settings like ours.

In this study, all our patients except one (who had exchange nailing for bent Kuntscher intramedullary nail of the femur) had open reduction and locked intramedullary nailing using external jigs for placement of locking screws with “Greens Instrumentation − India”.

There were 20 patients with 21 fractures (19 femoral and 2 tibial − same patient). The 20 patients were made up of 13 males and 7 females (M:F approx. − 1.5:1). The preponderance of males in varying degrees has also been reported in other previous similar studies.[1],[7],[9],[16] The reason for the male preponderance is not farfetched as males by virtue of their outgoing and risk taking activities being largely bread winners are more exposed to trauma than their female counterparts.[17],[18]

The average age of patients in this study was 42±18 years. This is higher than the average ages of patients reported in similar studies in and outside Nigeria[1],[8],[9],[19]; but similar to the mean of 41 years reported by Soren[7] from Kenya for open SIGN nailing of lower limb long bones.

Road traffic accident was the commonest aetiological factor for femoral and tibial shaft fractures in patients in this study. Similar findings have been recorded by several previous investigators.[1],[7],[8],[9] This is not surprising as road traffic accidents have been found to be the commonest cause of major trauma worldwide.[19],[20],[21],[22]

The preponderance of femoral fractures in patients who had open locked Intramedullary nailing for lower limb long bone fractures as observed in this study, has also been severally reported in previous studies.[3],[7],[8],[9] The reason for this observation is most likely because many tibial shaft fractures are still managed and tend to do well with other forms of treatment including external fixation for open fractures and conservative management with above knee casts for closed tibial shaft fractures and many Gustilo type 1 open fractures.[20],[21] As a result, the number of tibial shaft fractures treated with intramedullary nailing especially in resource poor settings like ours where most patients pay for treatment out of pocket is expectedly much lower than that for femoral shaft fractures where other forms of treatment are less effective with high complication rates and treatment failures.

A major advantage of locked intramedullary nailing of shaft fractures of the femur and tibia is that patients can start partial weight bearing relatively early when compared with other methods of treatment. However, the actual post-operative time of allowing patients to proceed on partial weight bearing appears to some extent to vary from immediate post-operative period to as late as 12 weeks or longer depending on individual surgeon’s preferences, the fracture pattern/personality, rigidity of fixation and other considerations including the presence of callous at fracture site. The average time to partial weight bearing in this study was 10 weeks (ranged from 6 to 12 weeks) post-operation. A time to partial weight bearing of 4–6 weeks has been reported by Ahmed[8] and Soren[7] in different studies, while Ikpeme et al.[9] allowed their patients to proceed with partial weight bearing only after an average of 12 weeks post-operation which according to them is guided by level of healing − presence of some callous at fracture site.

The union rate for reamed open intramedullary nailing of lower limb long bone shaft fractures in this study is also quite comparable to that reported from other previous studies using either closed or open nailing. If the 2 patients who died within 3 weeks from complications of co-morbid conditions are excluded, 17 (89.5%) of the remaining 19 fractures healed with patients bearing full weight in an average period of about 18.5 weeks. One of the patients who had intramedullary nailing for non-union from failed plate osteosynthesis had delayed union and had to undergo dynamization with bone grafting and eventually healed at 80 weeks post-operation bringing union rate to about 95%. The last patient had intramedullary nailing for pathological femoral shaft fracture from renal cancer. He died of complications of the renal cancer 18 months post-operation, but only achieved partial weight bearing till death. He had a large bone defect at the fracture site which was augmented with bone cement at surgery.This result is comparable to the ones previously reported in the literature by other authors who also used intramedullary nails (open or closed) in the treatment of femoral and tibial shaft fractures.

Ahmed,[8] in a study from Addis Ababa, reported a radiological/clinical union rate of 93.3% at an average of 7.4 weeks post-operation using open nailing with SIGN instrumentation. The reported time to union of 7.4 weeks is however relatively short compared with the average of 18.5 weeks observed in this study.

In another study from Kenya using SIGN nails/instrumentation, Soren[7] observed a union rate of 93% at 18.5 weeks after open IM nailing. Of note here is that the average time to union of 18.5 weeks is the same as observed in this study.

Ikpeme et al.[9] from Calabar in Nigeria also using SIGN instrumentation and nails for open nailing of femoral and tibial shaft fractures reported a union rate 97.3% at a mean union time of 16.9 +5.4 weeks (17.2 weeks for femur and 16.4 weeks for tibia). Partial weight bearing was commenced at 12 weeks in their study.

Erturer et al.[23] from Turkey recorded 93.6% initial union rate in femoral shaft fractures treated with undreamed closed locked intramedullary nails, additional 5.2% healed with dynamization with only 1.2% of patients requiring a reoperation and fixation with circular external fixator to achieve healing.

From the foregoing discussion, it is obvious that the GREEN’S instrumentation/nails for open intramedullary nailing of lower limb long bone shaft fractures is effective with acceptable results especially in resource-poor settings. Although not free (like the SIGN nail), the instrument and nails are relatively cheap and nailing does not require fracture table and intra-operative fluoroscopy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Olasinde AA, Oluwadiya KS, Olakunlehin OA, Adetan O. Locked Intramedullary Nailing of Femur and Tibia I a Semi-urban Area. Nig J Orthop Trauma 2011;10:89-91.  Back to cited text no. 1
    
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Dahiru IL, Amaefule KE, Lawal YZ, Ogirima MO, Maitama MI, Ejagwulu F, Abdulmalik MA. Locked intramedullary nailing for tibial and femoral fracture: challenges and prospects in a tertiary health care facility in a resource constrained setting. Arch Int Surg 2016;6:96-99.  Back to cited text no. 3
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Amupitan I, Michael OB, Onche II. Management of tibial shaft fractures using unreamed locked intramedullary nails: our experience from Jos, North Central Nigeria. IOSR-JDMS 2015;14:33-36.  Back to cited text no. 4
    
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Soren OO. Outcome of surgical implant generation network nail initiative in treatment of long bone shaft fractures in Kenya. East Afr Orthop J 2009;3:8-14.  Back to cited text no. 7
    
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Ikpeme I, Ngim N, Udosen A, Onuba O, Enembe O, Bello S. External jig aided intramedullary interlocking nailing of diaphyseal fractures : experience from a tropical developing centre. Int Orthop (SICOT) 2011;35:107-11.  Back to cited text no. 9
    
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Olasinde AA, Ogunlusi JD, Ikem IC. Outcome of the treatment of gunshot open fractures of the lower extremities with ‘SIGN’ interlocking nails. East Cent Afr J Surg 2012;17:38-42.  Back to cited text no. 11
    
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Folleras GI, Ahlo A, Stromsoe K, Ekeland E, Thoresen BO. Locked intramedullary nailing of fractures of the femur and tibia. Injury 1990;21:285-8.  Back to cited text no. 12
    
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Babis GC, Benetos LS, Karachalios T, Soucacos PN. Eight years’ clinical experience with the orthofix tibial nailing system in the treatment of tibial shaft fractures. Int J Care Injured 2007;38:227-34.  Back to cited text no. 13
    
14.
Hakan S, Hakan A, Hakan K, Yaruz OY, Mergen E. Antegrade locked nailing of adult femoral shaft fractures and non-unions: a retrospective review of 48 cases. Ankara Universitesi Tip Facultesi Mecmausi 2007;60:123-9.  Back to cited text no. 14
    
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Ibeanusi SEB, Ekere AU. Epidemiology of open tibial fractures in a teaching hospital. Port Harcourt Med J 2007;3:156-60.  Back to cited text no. 17
    
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21.
Ghosh S, Adak S, Chandhuri A, Roy DS, Chandhuri SK. Management of closed isolated tibial shaft fractures: a dilemma in a rural set up of a developing country. Med J DY Patil Univ 2014;7:738-43.  Back to cited text no. 21
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Lasen P, Elsoe R, Hansen SH, Graven-Nielsen I, Laessoe U, Rasmussen S. Incidence and epidemiology of tibial shaft fractures. Int J Care Injured 2015;46:746-50.  Back to cited text no. 22
    
23.
Erturer E, Ozturk I, Dirik Y, Uzun M, Aksoy B. Radiographic and functional results of osteosynthesis with locked unreamed intramedullary nailing of femoral shaft fractures in adults. Acta Orthop Traumatol Turk 2005;39:381-6.  Back to cited text no. 23
    


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