Attempted unreamed nailing in tibial fractures: a prospective consecutive series of 55 patients

We evaluated the possibility of unreamed insertion of an intramedullary nail (IMN) in a consecutive series of 55 tibial shaft fractures in 55 patients (30 men). 43 fractures were closed and 12 fractures were open. All surgeons involved were instructed to try unreamed insertion primarily. Selection of nail diameter was based on measurements of the narrowest part of the medullary canal on preoperative AP- and lateral radiographs, with a millimeter-ruler. Of the 25 cases where a 9 mm nail was chosen, 10 were impossible to insert without reaming. An 8 mm nail was selected in the remaining 30 cases, and here 10 required reaming. Mean time-to-union was 4.2 months. Delayed union was noted in 9 patients of whom 6 had been stabilized with an unreamed nail. The concept of unreamed insertion must be questioned since this could be done in only 35 patients and, in addition, we were not able to demonstrate any significant differences in time-to-union in fractures stabilized with an unreamed or a reamed nail. Implant failures were seen in 5 patients, all stabilized with an 8 mm nail. Failure of interlocking screws did not affect the final outcome. However, a possible combination of screw breakage and healing disturbances may lead to the need for more complex surgical procedures. Due to these reasons and the fact that the 8 mm nail could not be inserted unreamed in 10 of 30 patients, we stopped using the 8 mm nail.