ISSN 0972-978X 

  About COAA








Reamed Or Unreamed Nailing In Open Fractures Of Tibia – Current  Concepts.

Dr. P. Gopinath
Asst Professor in Orthopaedics
Medical College Calicut

Addresses for Correspondence

Dr. P. Gopinath
Asst Professor in Orthopaedics
Medical College Calicut

JJ.Orthopaedics 2005;2(3)e1


Open fractures of the tibia remain a formidable injury. External fixation has been the mainstay of treatment for the more severe fractures. This treatment option, however, is not without significant complications. Of particular importance is the rate of infection once the fixator is converted to a reamed intramedullary nail in cases of delayed union or nonunion. There is always a controversy regarding whether to use reamed or unreamed nailing in open tibial fractures. In this review article an attempt is made to understand the current concepts regarding whether to use reamed or unreamed nailing in open tibial fractures.


Bhandari M  et al concluded that there is no difference in out comes in reamed and unreamed groups. The relative merits of reamed versus unreamed nails in the treatment of open tibial fractures remain uncertain.1

Bizot P  et al inferred that  the risks of intramedullary tibial nailing are evaluated. Only one case presented a serious septic complication leading to nail removal and knee arthrodesis. Intramedullary nailing may be indicated in grade I and II non-unions, but should rarely be used in grades III and IV 2

Finkemeier  et al were of the opinion that  the use of reamed insertion of IM nails for the treatment of closed tibia fractures,  led to earlier union without increased complications. In addition, canal reaming did not increase the risk of complications in open tibia fractures.3

Freedman EL et al inferred that proximal third tibial fractures may require a neutral or slightly lateral entrance angle to ensure a more anatomic reduction and centromedullary nail orientation to offset the tendency for valgus angulation.4

Ketterl R  et al concluded that the rate of infection seen in open fractures was reduced by using an UTN for the tibia (4.5% using RTN versus 1.3% using UTN in primary implantation; 6.5% versus 4.3% in case of changing from EF to tibial nailing). The UTN does not disturb the healing of the fracture and there is no increased risk of axis deviation.5

Krettek C et al made the final conclusion in their study that  the overall results of AO Unreamemed tibial nail (UTN) was judged with the Karlstrom-Olerud score, which was applicable in 66 of 75 cases; excellent, n = 2; good, n = 22; satisfactory, n = 24; fair, n = 9; poor, n = 9. In the remaining nine cases no scoring was attempted because of severe injuries around the knee or ankle.6

Krettek C et al were of the opinion that unreamed nailing -which always relies on interlocking screws and is associated with function better than and infection rates similar to those with external fixation, but has an increased incidence of screw breakage. In contrast to the biological problems in the tibia, those problems encountered in the femur are more predominantly mechanical in origin7.

Lang GJ et al opined that Fractures of the proximal third of the tibial shaft do not appear to respond as favorably to intramedullary nailing as do fractures in the distal 2/3 of the tibia. Valgus, apex anterior angulation, and residual displacement at the fracture site are common after nailing. Surgical errors of a medialized nail entry point and a posteriorly and laterally directed nail insertion angle contributed to malalignment. Based on their findings, the authors have limited the use of intramedullary nailing for proximal third tibial shaft fracture and consider alternate forms of fixation (plate or external fixation).8

Muller CA concluded that  the results show that the same good infection rates were achieved for the UTN as for the external fixator. The advantages of the UTN are, however, a lesser need for secondary intervention and greater patient comfort. Therefore, we find the UTN to be a good alternative to the external fixator in the treatment of open fractures with severe soft tissue damage.9

Piccioni L et al concluded that retrospective review of the records of 20 patients who underwent unreamed, interlocked, intramedullary nailing for tibial fracture has shown that unreamed tibial rodding offers an excellent alternative to external fixation for the management of Grades I and II open tibial fractures. Additionally, for Grade III open fractures, this serves as an excellent form of preliminary stabilization, allowing the soft-tissue injury to heal.10

Runkel M, et al were of the opinion that  the use of unreamed nailing can be recommended, especially for open fractures and fractures with severe soft tissue damage.11

Richter D et al concluded that in cases treated with unreamed tibial nailing the highest rate of complications (22%) was seen in patients with distal fractures of the fibula without additional plating (of the fibula). There was no deep infection. Tibial fractures close to the ankle joint can be managed by unreamed nailing. Distal fractures of the fibula should be stabilized by additional plating. Because of the unreamed technique of implantation this procedure can also be used in grade II or III open fractures.12

Vecsei V et al opined that because of the success rate observed in the treatment of borderline indications for locked intramedullary nailing of femoral and tibial fractures and the improvement in equipment, training and techniques, we have expanded the indications for treatment of these fractures by intramedullary nailing.13

Weckbach A et al concluded that with primary data (type of fracture and grade of soft tissue injury) being comparable, we found an almost identical rate of infection for both techniques. Finally, unreamed nailing has been established as monorail procedure treating defect fractures by means of segmental transport.14 

Zelle BA concluded that exchange reamed nailing for nonunions of the tibia results in a high union rate and is associated with a low complication rate. This technique is recommended as a standard procedure for aseptic tibial nonunions after initial unreamed intramedullary nailing.15

 The author’s preferred method is to use unreamed tibial nailing in all open tibial fractures regardless of the severity of soft tissue injury provided stability can be achieved by this method5


Open fractures of the tibia remain an unsolved problem even in modern orthopedic practice External fixation has been the mainstay of treatment for the more severe injuries. But considering the post external fixation complication unreamed intramedullary nailing is viable option as a primary procedure. Many of the articles are in favour of unreamed  tibial nailing as a primary procedure with lesser compilcations



1. Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH. Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br. 2001 Jan;83(1):62-8.
2.Bizot P, Zucman J. Secondary nailing of the tibia in non-unions with septic risk. Indications and results Rev Chir Orthop Reparatrice Appar Mot. 1991;77(4):241
3.Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma. 2000 Mar-Apr;14(3):187-93.
4.Freedman EL, Johnson EE Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res. 1995 Jun;(315):25-33.
5.Gopinathan p et al  Short term follow up of un reamed interlocking nailing in compound fractures of tibia journal of calicut Ortho alumni association 2003 oct-dec 1(3)43-46.
6.Ketterl R, Leitner A, Wittwer W.Reducing the risk of infection by use of an unreamed intramedullary nail in open tibial fractures Zentralbl Chir. 1994;119(8):549-55.
7.Krettek C, Schandelmaier P, Rudolf J, Tscherne H. Current status of surgical technique for unreamed nailing of tibial shaft fractures with the UTN (unreamed tibia nail)] : Unfallchirurg. 1994 Nov;97(11):575-99.
8.Krettek C, Gluer S, Schandelmaier P, Tscherne H Intramedullary nailing of open fractures. Orthopade. 1996 Jun;25(3):223-33.
9. Lang GJ, Cohen BE, Bosse MJ, Kellam JF. Proximal third tibial shaft fractures. Should they be nailed? : Clin Orthop Relat Res. 1995 Jun;(315):64-74
10. Muller CA, Dietrich M, Morakis P, Pfister U. Clinical results of primary intramedullary osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft fractures Unfallchirurg. 1998 Nov;101(11):830-7.
11.Piccioni L, Guanche CA. Clinical experience with unreamed locked nails for open tibial fractures. : Orthop Rev. 1992 Oct;21(10):1213-9.
12.Runkel M, Wenda K, Stelzig A, Rahn BA, Storkel S, Ritter G Bone remodeling after reamed and unreamed intramedullary nailing. A histomorphometric study] Unfallchirurg. 1994 Aug;97(8):385-90.
13.Richter D, Hahn MP, Laun RA, Ekkernkamp A, Muhr G, Ostermann PA. Ankle para-articular tibial fracture. Is osteosynthesis with the unreamed intramedullary nail adequate? Chirurg. 1998 May;69(5):563-70.
14.Vecsei V, Seitz H, Greitbauer M, Heinz T. Borderline indications for locked intramedullary nailing of femur and tibia : Orthopade. 1996 Jun;25(3):234-46.
15. Weckbach A, Blattert TR, Kunz E. Differential indications for intramedullary nailing of the tibia with the reamed and unreamed technique] Zentralbl Chir. 1994;119(8):556-63.
16.Zelle BA, Gruen GS, Klatt B, Haemmerle MJ, Rosenblum WJ, Prayson MJ Exchange reamed nailing for aseptic nonunion of the tibia. : J Trauma. 2004 Nov;57(5):1053-9


 This is a peer reviewed paper 

Please cite as :
P Gopinath: Reamed or unreamed nailing in open fractures of tibia –         current  concepts
J.Orthopaedics 2005;2(3)e1






Arthrocon 2014


13th Summer Meet,16th March,2014

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044



Powered by



© Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.