Does open reduction increase the chance of infection during intramedullary nailing of closed tibial shaft fractures?

Peter Tang, Charley Gates, Justin Hawes, Molly Vogt, Michael J Prayson
Journal of Orthopaedic Trauma 2006, 20 (5): 317-22

OBJECTIVE: To evaluate whether an open technique used to obtain reduction during intramedullary nailing of closed tibial shaft fractures increases the risk of infection, compared to closed reduction and nailing.

SETTING: University level 1 trauma center.

DESIGN: Retrospective database analysis.

PATIENTS/PARTICIPANTS: One hundred seventeen patients with 119 fractures from our trauma database who had sufficient follow-up and met study criteria. The patients were grouped by open versus closed reduction. Only OTA fracture types 42 A to C were included in this study.

INTERVENTION: Locked reamed intramedullary nailing for closed tibial shaft fractures accomplished through either open or closed reduction.

MAIN OUTCOME MEASUREMENT: The presence or absence of infection as determined by the clinical presentation (erythema, warmth, purulent drainage, fevers, chills, increased pain at the fracture site), indicative laboratory work (complete blood count, erythrocyte sedimentation rate, C-reactive protein), and/or positive culture.

RESULTS: There were 85 males and 32 females. The average age was 35.7 years; the average follow-up was 14.3 months. Of the 119 fractures, 79 had closed reduction whereas 40 had open reduction. The open reductions consisted of 13 with a formal incision (>1 cm in length), 22 with percutaneous incisions, and 5 with fasciotomies. There were no infections in the closed reduction group and 2 infections (5%) in the open reduction group. This difference was not statistically significant (P=0.1). The average time to union was 7.0 months in closed reductions and 7.3 months in open reductions. By latest follow-up, 107 fractures had reached union (89.9%), 1 had not (0.8%), and 11 were lost to final follow-up (9.2%).

CONCLUSIONS: Limited open techniques can greatly facilitate the reduction of closed tibial shaft fractures but raise concern for infection through exposure of the fracture site. This study found that the rate of infection for open versus closed reductions was higher but not statistically different. Judicious use of open reduction techniques during intramedullary nailing of closed tibia fractures seems to have a minimal risk of infection.

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