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Re: Еще один перелом "около фиксатора"
Alexander Chelnokov 28 Январь 2004, 21:39
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MC> likely to succeed. I hope you will give us some follow-up in 3
MC> months.
I'll try.
MC> My question (purely to keep the discussion alive :-) is why
MC> do you use an unreamed technique?
Just because we have only solid nails, and 13 mm is a thickest available one, and due to her osteoporosis the nail passed through the canal without reaming.
MC> nailing, measured by Trans Esophageal Echo-cardiogram. So what is
MC> the advantage of unreamed nails? In this particular case?
I completely agree that for primary nailing the only advantage of unreamed technique is few saved minutes.
MC> better spent comparing reamed IM fixation of the tibia to
MC> percutaneous plate fixation or ex fix.
Do you really suppose this topic is so actual? Differencies looks so self-evident.
MC> Is everyone aware that there have never been a randomized
MC> prospective trial in closed tibial fractures to show that IM nails
MC> are superior to old fashioned AO plates?!
As i realize the rigorous study design is required for situations where advantages of one technique over another are not so evident.
MC> randomized controlled trial to show that total hip replacement is
MC> better than a Girldlestone; but I submit that the case for nailing
MC> tibias is much less secure.
Can't enough evidence be provided with retrospective studies?
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Re: Еще один перелом "около фиксатора"
Myles Clough 28 Январь 2004, 21:51
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Alex> Can't enough evidence be provided with retrospective studies?
>
The largest metaanalysis on this subject was published in 1999 in the Canadian Journal of Surgery. The following is the
abstract
10166. Coles, C. P. and Gross, M.,
Closed tibial shaft fractures: management and treatment complications. A review of the
prospective literature. Can.J Surg 43:256-262, 2000.
OBJECTIVE: To compare the results and complications of the various modalities for treating closed fractures of the tibial shaft described in the prospective literature.
DATA SOURCES: A MEDLINE search of the English language literature from 1966 to 1999 was conducted using the MeSH heading "tibial fractures." Studies pertaining to the management of closed tibial shaft fractures were reviewed, and their reference lists were searched for
additional articles.
STUDY SELECTION: An analysis of the relevant prospective, randomized controlled trials was performed. Studies including confounding data on open fractures or fractures in children were excluded. The 13 remaining studies were reviewed.
DATA EXTRACTION: Raw data were extracted and pooled for each method of treatment.
DATA SYNTHESIS: The 13 studies described 895 tibial shaft fractures treated by application of a plaster cast, fixation with plate and screws, and reamed or unreamed intramedullary nailing. Although definitions varied, the combined incidence of delayed and nonunion was lower with operative treatment (2.6% with plate fixation, 8.0% with reamed nailing and 16.7% with unreamed nailing) than with closed treatment (17.2%). The incidence of malunion was similarly lower with operative treatment (0% with plate fixation, 3.2% with reamed nailing and 11.8% with unreamed nailing) than with closed treatment (31.7%). Superficial infection was most common with plate fixation (9.0%) compared with 2.9% for reamed nailing, 0.5% for unreamed nailing and 0% for closed treatment. The incidence of osteomyelitis was similar for all groups. Rates of reoperation ranged from 4.7% to 23.1%. CONCLUSIONS: All forms of treatment for tibial shaft fractures are associated with complications. A knowledge of the incidence of each complication facilitates the consent process. To fully resolve the controversy as to the best method of treatment, a large, randomized, controlled trial is required. This review more precisely predicts the expected incidence of complications, allowing the numbers of required patients to be more accurately determined for future randomized controlled studies
Highlights are
- delayed, non-union and malunion lower with plates
- superficial infection more common with plates
- deep infection the same for all treatment groups.
So, no! I don't think the advantages of one technique over another are self-evident; except that unreamed tibial nails seem to be the worst option. I do emphatically think the subject needs to be subjected to rigorous scientific investigation. Since that study closed in 1999 we have begun to use periarticular plates which can be inserted in a closed fashion with just a small opening at top and bottom leaving the blood supply of the fracture fragments undisturbed. On the other hand, perhaps we have become more skilled at doing closed IM rod fixation and so have less malunions.
See additional Tibial Fracture websites C.M.Court-Brown's 1998 review The management of femoral and tibial diaphyseal fractures AO Publishing Bibliography on treatment of the Tibial Shaft fracture Royal College of Surgeons of Edinburgh summary on Tibial Shaft fractures
Socioeconomic Burden of Traumatic Tibial Fractures: Nonunion or Delayed Union (Medscape)
Tibial Fractures Bibliography with abstracts from George Washington University
Myles Clough
mylesclough@shaw.ca
Orthopaedic Surgeon, Kamloops, BC, Canada
Clinical Instructor, University of British Columbia
President, Internet Society of Orthopaedic Surgery and Trauma http://www.isost.com
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