Ortho-Preferred

Reaming of Tibial Fractures


- Discussion:
    - effect on tibial bone supply: (see blood supply to the tibia)
          - unreamed nails theoretically minimizes disruption of the endosteal vasculature;
          - references:
                - Early changes in nutrient artery blood flow following tibial nailing with and without reaming: a preliminary study.
                - Effect of limited and standard reaming on cortical bone blood flow and early strength of union following segmental fracture. 
                - Comparison of the effect of reamed and unreamed locked intramedullary nailing on blood flow in the callus and strength of union following fracture of the sheep tibia.
                - Cortical bone blood flow in reamed and unreamed locked intramedullary nailing: a fractured tibia model in sheep.
    - reamimg of open tibia fractures (see IM nailing of open tibia fractures)
          - references:
                 - Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study. 
                 - Reamed interlocking intramedullary nailing of open fractures of the tibia.
                 - A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft.      
                 - Reamed nailing of open tibial fractures: does the antibiotic bead pouch reduce the deep infection rate?
    - limited reaming:
          - there is some evidence to suggest that limited reaming may spare cortical perfusion compared to standard reaming;
          - w/ more flexible titanium nails over-ream by only 0.5 mm, where as more rigid nails will need to be over-reamed by 1 mm;
          - generally, w/ rigid stainless steel nails the canal is reamed 1 mm more than the size of the IM nail;
          - references:
                - Effect of limited and standard reaming on cortical bone blood flow and early strength of union following segmental fracture. 

    - outcome studies:
          - as pointed out by Blachut, et al (1997), in closed fractures, there is no advantage to nailing w/o reaming;
                 - unreamed nails are more prone to have frx non union (89 vs 96%) and are more prone to have breakage of the interlocking screws;
                 - compartment syndrome did not occur more frequently w/ reamed nails;
          - despite the recent interest in nonreamed interlocking intramedullary nailing for open tibial fractures, there is good evidence to suggest that
                  reamed interlocking nails result in a lower rate of complications (screw breakage) and have a similar time to bone union (Keating JF, et al, (1997));
          - references:
                  - Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. 
                  - Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study.
                  - A Meta-analysis of Reamed Versus Unreamed Intramedullary Nailing for the Treatment of Closed Tibial Fractures



- Technical Considerations:
    - avoid thermal necrosis:
           - never inflate the tourniquet during the reaming process, since thermal necrosis of the bone may occur;
    - avoid eccentric reaming:
           - use flouroscopy to ensure that the guide wire has passed centrally down the medullar canal on both AP and lateral views;
           - it is useful for the guide wire to have a small curve at its distal end in order to allow the wire to be centrally re-directed as it is driven distally;
           - use flouroscopy to observe the passage of the reamer across the frx site (inorder to ensure that eccentric reaming is not taking place);
           - if eccentric reaming is occuring, then manipulate the frx site to faciliate passage of the reamer;
                  - if eccentric reaming has taken place, the nail will naturally follow the path of least resistance and will therefore remain eccentric
                           within the medullary canal





Thermal necrosis after tibial reaming for intramedullary nail fixation. A report of three cases

Reamed or unreamed nailing for closed tibial fractures. A prospective study in Tscherne C1 fractures.

Complications of reamed intramedullary nailing of the tibia.

Fatigue failure in small diameter tibial nails.

Mechanical failures of intramedullary tibial nails applied without reaming.

Friction burns within the tibia during reaming. Are they affected by the use of a tourniquet?

Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years' follow-up.

The thermal effects of intramedullary reaming.

Intramedullary nailing in open tibia fractures: a comparison of two techniques.

Reaming versus non-reaming in medullary nailing: interference with cortical circulation of the canine tibia.

Thermal necrosis complicating reamed intramedullary nailing of a closed tibial diaphysis fracture: a case report

The Effect of Intramedullary Reaming on a Diaphyseal Bone Defect of the Tibia.

Reamed versus minimally reamed nailing: A prospectively randomised study of 100 patients with closed fractures of the tibia



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, September 12, 2014 9:35 am