The tibia is the most commonly broken long bone in the body, with two fractures per 1000 persons annually. Given that the tibia is a long bone and one of the primary load- bearing bones in the lower extremities, fractures can result in severe disability and protracted morbidity if treatment is not received. The shaft fractures of the tibia can now be treated using numerous procedures; however, an orthopaedic surgeon must be knowledgeable about the benefits, drawbacks, and limitations of each technique in order to choose the best course of action for each patient. The type, location, level of communication, age, and social and economic needs of the patient may all affect the treatment plan. When tibial fractures resulting from high-energy forces or those that are widely displaced are treated nonoperatively, the outcome is often poor function, stiffness in the joint, and a high incidence of malunion. In 1961, Sir John Charnley observed, ―It may take extensive research before the most effective way to treat a tibia shaft fracture can be determined definitively. (1) Due to its exact placement, Tibia is often vulnerable to injury. Due to the fact that one-third of its surface is subcutaneous, open fractures are common. Moreover, the tibia’s blood supply is already unstable and is protected from further damage by the ankle and knee hinge joints, which do not let the rotatory deformity to be adjusted. According to Sisk (1983) (2), ―there are clear drawbacks when treating diaphyseal fractures with methods that necessitate extended immobilisation of the extremities. Long-term hospitalisation, convalescence, or both are prevalent, joint movement restriction is frequent, and non-union and malunion can happen. The method of treating fractures that is unachievably perfect would safely fuse the fracture together so strongly that joints and soft tissues may be mobilised early and often during the healing process. In certain cases, walking and bearing weight could also be allowed. Intramedullary fixation is a technique that is very similar to this. Long-term immobilisation in a functional cast brace or plaster of Paris cast has been the usual therapy for tibial shaft fractures; this invites the well-known ―Fracture – disease‖ condition. With the widely used Sarmiento type PTB functional brace, average shortening is 6.4 mm, average angulation is 8°, and average union time is 5.7 months. Sarmiento Plaster, 1981; Austin, RT. (3) The intramedullary interlocking nail revolution has mostly overcome these limitations. The sheet anchor’s continued use, its capacity to stop axial collapse, rotational, and angulation abnormalities, and above all its capacity to allow for the earliest ambulation feasible all serve to maintain this treatment modality’s high priority. As early as 1974, Nicoll noted that the likelihood of a comminuted fracture with delayed union is 15%, a displaced fracture is 27%, a fracture with soft tissue damage of more severity is 12%, and a fracture gap larger than 1 cm is 65% when conservative therapy is used. (4) Additionally, a quarter of cases had persistent muscular weakness and joint stiffness. Because of the tibia’s superficial location just beneath the skin, treating the shaft fractures of the tibia may present few challenges: (1) a high frequency of open and infected fractures. (2) a tendency for the fragments to realign when swelling goes down, especially in oblique and spiral fractures. Because the knee and ankle joints generally move in the same parallel axis, any improper alignment or rotational orientation of the fragment may result in. (a) cosmetic and occasionally functional handicap. (b) conspicuous disfigurement if the pieces are positioned imperfectly because of the tibia’s subcutaneous location. (c) a delayed union because of the severity of the fracture, inadequate blood flow to one fragment, and occasionally bone fragment distraction. (d) the sporadic restrictions on knee, ankle, and foot joint mobility, typically brought on by a related soft tissue, joint, or vascular injury (Watson Jones2 ,1982). (5) Later, throughout the ninth decade, closed intramedullary nailing became a recognised treatment for closed shaft fractures due to the capacity to lock the nail both proximally and distally (Kuntscher3 1962; Hoentzsch et al, 1989). (6,7) However, adverse reactions to the traditional reaming approach have been reported; these are likely the result of biological, mechanical, and thermal variables that compromise the endosteal blood supply (Pfister et al., 1979; Klein et al., 1990). (8,9) For both closed and Gustilo grade I open fractures, locking nails have demonstrated positive outcomes (Gustilo and Anderson4 1976; Kfemn and Broner, 1986; Court-Brown et al5 1990; Hooper et al6 1991) (10–13). Closed nailing without reaming, followed by early weight-bearing and ambulation, provides advantages over all other current techniques, with a notably lower rate of complications and comparable outcomes. It has the following advantages over A.O. technique: (1) It doesn’t require specialised technique, as difficulties from A.O. procedures have been attributed to a lack of experience (Thunold et al, 1975). (14) (2) special equipment not required. (3) being better suitable for high-energy fractures and requiring less specialised tools (Bauer et al7 1962; Edwards8 1965). (15,16) It has been shown that the most effective method for repairing these fractures is interlocking intramedullary nailing. Better and faster fracture unions are achieved by the intramedullary nailing under image intensifier, which satisfies the goal of stable fixation with little tissue injury. Treatment for diaphyseal shaft fractures of the tibia has been documented to involve the use of intramedullary nailing, whether reamed or unreamed technique. Additionally, each has a distinct benefit when it comes to fracture healing: unreamed nailing provides far greater blood flow to the cortex, whereas reamed nailing has a more rigid structure and a faster fracture union. The efficacy of reamed and unreamed nailing procedures for the treatment of the shaft fractures of the tibia, however, remains controversial. This study aims to assess the results of intramedullary interlocking nailing whether reamed or unreamed technique for diaphyseal shaft fractures of the tibia. For the purpose of treating tibial diaphyseal shaft fractures, this study analysed the differences between reamed and unreamed intramedullary nailing groups in terms of postoperative infection, osteofascial compartment syndrome, implant failure rates, and postoperative healing rates. AIMS : This study is to present an analysis on functional outcome and union rates on reamed versus unreamed intramedullary interlocking nailing in tibial shaft fractures. OBJECTIVES: 1. To investigate and assess the healing process of diaphyseal fractures using reamed versus unreamed intramedullary nailing. 2. To determine the technological challenges and mistakes present in the process. 3. For assessment of the functional outcome as early as possible and to the greatest extent. 4. For evaluation of the post-operative non-union and delayed-union fracture problems that are related. 5. To examine the alignment and stability of rotation, demonstrating its impact on fracture union, mal-union, and non-union.

This is a retrospective study conducted between the period OCTOBER 2022 to JUNE 2024. Source Material The source material comprised of data collected from the patients, who were admitted in Government General Hospital, Guntur attached to Guntur Medical College, 20-70 years clinically having diaphyseal fracture of the Tibia which may be open or closed fractures mainly of the proximal to middle and distal third supported by radiological investigations, operative and post-operative findings. These will be taken up for study after obtaining their informed consent. Case Selection: All patients above 18 years of age, of either sex, presenting with closed fractures classified according to the Tscherne classification and open fractures classified according to the Gustilo–Anderson classification involving the diaphysis of the tibia were included in the s tudy. These patients were treated with dynamic intramedullary interlocking nailing, either with or without reaming (10,17). Only patients who were fit for spinal anaesthesia and did not have associated major head, chest, or abdominal injuries were selected for inclusion in the study. Inclusion criteria • Adults both males and females aged between 18-70 years and who gave informed consent. • Patients with Closed fractures according to TSCHERNE classification. (17) • Isolated diaphyseal fractures of Tibia in patients who are skeletally mature. • Patients with open fractures (GUSTLIO ANDERSON CLASSIFICATION) type I, II, III A. (10) Exclusion criteria • Patients who have upper third and distal third intra- articular fractures of Tibia. • Patients with Compound grade (type IIIB, IIIC – GUSTLIO ANDERSON CLASSIFICATION) Tibia. • Pathological fractures Associated co-morbid conditions making the patient medically unfit for surgery. Data collection will be conducted using standard case proforma. The following protocol served as the foundation for the injury’s treatment. Initial Management and Resuscitation 1) After the patient arrived at the emergency room, his vital signs were noted and kept track of. 2) Head, chest, abdominal, and related limb injuries were ruled out. 3) A pressure bandage was used to stop the bleeding from the wound, tetanus prophylaxis and intravenous cephalosporin antibiotics were administered, and fluid replacement was initiated. 4) If the area around the fracture site was cleansed and bandaged, a slab from the groin to the toes may be applied by only aligning the bones. Any more wounds were carefully treated. 5) After recovering from the acute injuries, the patient was moved to the orthopaedic ward. PATIENT HISTORY A thorough medical history was obtained of every patient who was admitted, with special attention paid to the following details: age, sex, occupation, mode of injury, duration of injury, therapy received (if any), related medical and surgical illness (if any), and socioeconomic position. EXAMINATION • A comprehensive physical examination was performed, and the patient’s condition was evaluated by recording their vital signs—heart rate, blood pressure, breathing, and, if present, pallor. • To identify any prior medical and surgical conditions, particularly those related to the heart, lungs, or kidneys, a systemic examination was carried out. • In order to prevent overlooking any more related injuries, a thorough check of every limb—not just the damaged one—was conducted. • A local examination of the affected extremity was done to determine the deformity, level of swelling, local discomfort, aberrant movement, crepitus, skin integrity, discoloration, and symptoms of compartment syndrome. In every instance, the neurovascular state was noted. • Each case’s limb length was measured, and the amount of shortening was noted. Any related injuries were noted, and appropriate care was given. Every instance included a recording of the range of motion. • Fast medical consultation was requested for elderly people. • To rule out polytrauma, a general surgeon’s consultation was requested for the evaluation of all high intensity accident victims. INVESTIGATIONS • X-RAYS of the affected limb were taken. • X-RAY chest was done to diagnose any pre-existing chest disease. • Radiographic evaluation included anteroposterior and lateral radiographs of the entire leg, including the knee joint and the ankle joint. Routine Blood Investigations • Blood grouping and typing and cross matching • Haemoglobin percentage, packed cell volume (PCV) • Complete blood count, erythrocyte sedimentation rate, bleeding time, clotting time, prothrombin time. • Random blood sugar, blood urea, serum creatinine, serum uric acid. • HIV, HBsAg, HCV • Urine Routine • Urine for macroscopy, sugar, albumin and microscopy. Special Tests • ECG, ABG, Chest X-Ray PA view, others • 3 dimensional CT scan (if required) • Colour Doppler: When vascular injury suspected. MANAGEMENT The patient was stabilised and immobilised for the fresh tibial fractures in an above- knee plaster of Paris slab. Any related injuries as well as any surgical or medical illnesses were handled appropriately. As soon as the patients were anaesthetized fit, interlocking nails were used throughout surgery. PREOPERATIVE PREPARATION OF PATIENTS: i. Prior to surgery, patients were kept NBM for 6–8 hours. ii. IV fluids were administered as needed. iii. Enough suitable blood can be arranged if necessary. iv. The entire limb, the intimate areas, and the back were prepared. v. Informed and written consent was obtained. vi. Patient was given a soap water enema at night. vii. Thirty minutes prior to surgery, IV antibiotics were administered. viii. Patient being moved to the operating room thirty minutes prior to surgery. ix. Preoperatively, the medullary canal is measured at the isthmus on x-rays, and the length of the nail is determined by deducting 2-3 cm from the measurement made from the knee joint line to the tip of the medial malleolus. Alternatively, TMD is measured from the base of the medial malleolus to the tip of the tibial tuberosity. As a result, a supply of interlocking nails was always maintained, 2 cm above and below the measurement and 1 mm above and below the necessary diameter. In our situations, we have utilised cannulated tibial nails. INCISION AND ENTRY POINT: A 5 cm linear incision is made extending from inferior pole of patella to superior border of tibial tuberosity. Along the incision the skin, fascia are incised and retracted. The patellar tendon is given a Longitudinal split and the entry is made into the knee joint with the bone awl. The ideal starting point is just medial to lateral tibial spine. The ideal entry point seen on AP view is located 9mm lateral to centre of the tibia plateau and slightly lateral to the tibial tubercle. On the lateral view the entry point is anterior to the articular margin. INSERTION OF GUIDE WIRE: With the help of blunt periosteal elevator or using surgeons index finger, the guide wire is inserted into the medullary canal directly under the patella. This is done with knee flexion of more than 90o. PROCEDURE OF REAMING: After making assurance of the position of the guide wire crossing the fracture site into distal fracture fragment under the guidance of fluoroscopy, the entry reamer is introduced to open the medullary canal. Sequential reaming is done with help of rigid 8mm/9mm/10mm/11mm/12mm or flexible reamers of sizes of 8mm/8.5mm/9mm/9.5mm/10mm/10.5mm/11mm/11.5mm/12mm. • If fracture is highly comminuted reduction forceps, clamps, blocking screws can be used in reduction of the fracture. • In unreamed nails this step is skipped directly to placement of nail. PLACEMENT OF NAIL: After intramedullary reaming, the nail diameter is determined by 1mm less than that of rigid reamer or 1.5 mm less than that of the flexible reamer, then properly selected nail inserted. Both AP and lateral alignment should be monitored, when nail is passed through the fracture site and distal positioning and proximal seating all are best seen in lateral fluoroscopic view. Proximal interlocking is done followed by distal interlocking screws. If compression is required at the fracture site, distal locking is done first under fluoroscopic guidance. • Reduction and fixation was checked under fluoroscopic guidance and found to be satisfactory, thorough wound wash given with normal saline. • A full knee ROM should be done for verification of patellar tracking and the wounds are closed in layers. • Sterile dressing applied. • Limb is advised to be kept in elevation. • Continue taking cephalosporin antibiotics until the sutures are removed Post-Operative physiotherapy: • Active toe movements are encouraged, and the limb is maintained elevated at all times. • The patient’s distal circulation, discomfort, and excessive oedema are monitored. • Two days following the procedure, the first dressing is applied, followed by second and third dressings on 5 and 8 post operated days. • After 10 to 12 days, under complete asepsis, suture removal is performed if the suture line is clear. • A crepe bandage is placed from the knee to the ankle. • After dressing, active mobilisation of the knees and ankles is initiated right away. • Starting to bear some weight while using walker support. • If feasible, gait training on parallel bars can also be performed; a one-month reassessment is recommended. • Based on the patient’s level of pain and the integrity of the fracture fixation, recommendations are made regarding complete weight-bearing. Follow-up and Evaluation The patient is usually followed up at 2 weeks, 6 weeks, 12 weeks, 6months, 12months, 18 months. Check X-rays are taken at every visit and patient is assessed clinically for fracture union. The Alho and Ekeland criteria are used to evaluate the anatomical results. (19) The JOHNER’S and WRUH’S criteria is used to evaluate the functional results of outcome. (20)

A total of 45 patients who assessed with inclusion and exclusion criteria were selected for our study. All of them belonged to the age group of 20-70. The youngest patients was of 20 years and the eldest was of 69 years. Most of the patients were between the age of 40 and 50. There was no statistically significant relationship between age and outcome. AGE REAMED UNREAMED 20-30 4 3 31-40 7 2 41-50 10 9 51-60 1 1 61-70 6 2 GENDER DISTRIBUTION Out of the 45 patients selected for the study 32 were males and 13 were females. More number of males were seen in our study. In the reamed group there were more males and the unreamed group comprised of both males and females in similar number with a mild female preponderance GENDER REAMED UNREAMED MALE 25 7 FEMALE 4 9 MODE OF INJURY The common modes of injuries resulting in tibial fractures are road traffic accidents and fall from height. Most tibial shaft fractures occurred along with fibular shaft. All of them were a result of high velocity trauma. In our study 40 cases were results of road traffic accidents ad 5 were due to fall from height. MOI REAMED UNREAMED RTA 26 14 FALL 3 2 SIDE DISTRIBUTION There was a similar number of tibial shaft fractures of the right side and left side. There were 22 cases with fracture over the left leg and 23 cases with fracture over the right leg. This had no statistical significance SIDE REAMED UNREAMED LEFT 13 9 RIGHT 16 7 CLASSIFICATION OF FRACTURES All fractures were broadly classified as open or closed. There were a total of 30 closed fractures and 15 open fractures. The compound fractures were classified according to Gustilo and Anderson classification. The majority of the open fractures were type 2 CLASSIFICATION REAMED UNREAMED CLOSED 25 5 OPEN 4 11 TIME FOR UNION Based on the radiological union score of tibia (RUST) post operative fracture union was confirmed. Regular followups were done for all 45 patients with both AP and lateral leg X-rays. TIME FOR UNION REAMED UNREAMED 0-4 MONTHS 23 1 4-6 MONTHS 3 10 6-9 MONTHS 1 4 >9MONTHS 1 2 OUTCOME Based on Johner and Wruh's Criteria final outcome of the surgery was assessed. The outcomes were divided as Excellent, good, fair and poor. Out of the 45 cases 22 had excellent outcome, 13 had good outcome, 6 had fair and 4 patients had poor outcome OUTCOME REAMED UNREAMED EXCELLENT 20 2 GOOD 7 6 FAIR 1 5 POOR 1 3 COMPLICATIONS The major complications encountered in our study were Infection followed by anterior knee pain, non union, delayed union and malunion COMPLICATION REAMED UNREAMED INFECTION 4 4 ANTERIOR KNEE PAIN 6 1 NON UNION 0 2 DELAYED UNION 0 1 MALUNION 1 0 SECONDARY PROCEDURES The secondary procedure done in our study were dynamisation of the intramedllary nail, bone grafting, exchange nailing, secondary suturing, debridement and split skin grafting SECONDARY PROCEDURE REAMED UNREAMED DYNAMISATION 2 2 BONE GRAFT 0 2 EXCHANGE NAIL 1 1 SECONDARY SUTURE 0 1 DEBRIDEMENT 0 1 SSG 0 2

As there are more motor vehicles on the road in India, there is an increasing number of trauma cases resulting from traffic accidents . Indirect injuries usually result from low-energy trauma, whereas direct injuries usually result from high-energy trauma . The majority of individuals sustaining tibial shaft fractures are young and middle-aged adults. Because of their superficial location, tibial fractures are more common . The tibial shaft has a precarious blood supply and a lack of a soft-tissue envelope, which increases the risk of infection and non-union in these fractures . In the past, tibial shaft fractures have been managed using numerous techniques, including plating, external fixation, reamed or unreamed intramedullary nailing, and functional bracing . Treatment of tibial shaft fractures aims to restore pre-injury anatomy and function while minimizing complications . Immobilization in an above-knee plaster cast and fixation with plates and screws have been associated with unacceptably high infection rates. The disadvantages of external fixation include bulky frames, frequent pin-tract infections, non-union, malunion, and poor patient compliance . Because they are inserted without reaming, intramedullary devices such as Ender nails have low postoperative infection rates; however, they are unable to adequately stabilize comminuted fractures and are associated with an increased risk of limb shortening and fracture displacement. Locking of intramedullary nails at both proximal and distal ends reduces malunion and provides improved stability. Intramedullary nailing offers several advantages in the treatment of tibial shaft fractures, including closed reduction with preservation of the periosteal blood supply, early mobilization of the knee and ankle joints, ease of postoperative limb monitoring, low infection rates even in compound fractures with compromised soft-tissue envelopes, and a high likelihood of fracture union. Improved biomechanical stability and early return to work are further facilitated by the use of interlocking intramedullary nails . With regard to intramedullary nailing, the ongoing debate concerns whether reaming is necessary. Reamed intramedullary nailing has been associated with disadvantages such as disruption of endosteal blood flow, longer recovery periods, compartment syndrome, thermal bone necrosis, and infection. However, reaming also offers advantages, including increased cortical blood flow and superior mechanical stability due to the use of larger-diameter nails . This prospective study aims to determine whether reamed intramedullary nailing of tibial shaft fractures is superior to unreamed intramedullary nailing in terms of outcomes and complications. A total of 45 patients were included in the study. All patients belonged to the 20–70-year age group, with the youngest patient being 20 years and the oldest 69 years. The majority of patients were between 40 and 50 years of age. There was no statistically significant relationship between age and outcome. Although the present study included a relatively smaller sample size of 45 patients, it is comparable with several published studies. Manjeet Singh et al. evaluated outcomes in 30 patients with tibial shaft fractures (22). Schemitsch et al. conducted a larger multicentric study involving 1,228 patients (23). Dinesh Choudhary et al. included 20 patients in the reamed group and 18 patients in the unreamed group (24). Deleanu et al. studied 41 patients in the reamed group and 43 patients in the unreamed group (25). COMPARISON OF STUDIES: REAMED VS UNREAMED INTRAMEDULLARY NAILING Study Reamed (n) Unreamed (n) Singh et al. (22) 15 15 Schemitsch et al. (23) 622 604 Chowdhary et al. (24) 20 18 Deleanu et al. (25) 41 43 Present study 29 16 COMPARISON OF MEAN AGE (YEARS): REAMED VS UNREAMED GROUPS Study Reamed (years) Unreamed (years) Singh et al. (22) 37.07 37 Chowdhary et al. (24) 25 27 Present study 41 40 The mean age in the present study was 41 years in the reamed group and 40 years in the unreamed group, which was comparable to the studies published by Singh et al. (22) and Chowdhary et al. (24). There was no statistically significant association between the age of the patient and the outcome of surgery. Most patients involved in road traffic accidents in India are males, which was reflected by the male preponderance observed in the present study. Similar findings have been reported in other Indian urban studies . In contrast, Deleanu et al. reported an almost equal distribution of males and females in their study conducted in France (25). On statistical analysis, no significant correlation was observed between gender and functional outcome or fracture union rates. GENDER DISTRIBUTION COMPARISON Study Male (%) Female (%) Singh et al. (22) 70 30 Chowdhary et al. (24) 79 21 Deleanu et al. (25) 52 48 Present study 71 29 The traditional definition of fracture union in tibial diaphyseal fractures treated with functional bracing, as described by Sarmiento et al., includes absence of pain on weight bearing, no abnormal movement at the fracture site, and visible callus formation on radiographs (26). However, reliance solely on clinical assessment of stiffness and weight-bearing capacity has been shown to be unreliable, despite evidence that weight-bearing ability correlates reasonably well with fracture stiffness in tibial fractures treated with external fixation. Webb et al. demonstrated that manual assessment of fracture stiffness by medical students was no less accurate than that performed by orthopaedic surgeons (27). Further studies have shown that surgeons demonstrate significant variability and inconsistency when assessing progressive fracture stiffness over time, regardless of their level of experience. To overcome these limitations, Whelan et al.(37) developed the Radiographic Union Score for Tibial fractures (RUST) as a standardized method for evaluating fracture healing following intramedullary nailing . This scoring system was further validated to standardize radiographic assessment of tibial fracture union . The RUST score evaluates cortical bridging, which has been shown in experimental and in vivo models to correlate with the biomechanical strength of the fracture site . In the present study, the RUST score was used to assess fracture union. COMPARISON OF MEAN UNION TIME: REAMED VS UNREAMED Study Reamed Unreamed Singh et al. (22) 13.87 weeks 14.27 weeks Chowdhary et al. (24) 20.5 weeks 22.5 weeks Deleanu et al. (25) 3.2 months 3.4 months Present study 4.5 months 7.73 months In the reamed group, a mean union time of 4.5 months was observed, whereas in the unreamed group the mean union time was 7.73 months. On comparison with peer studies, a relatively longer union time was noted in the unreamed group; however, the difference observed in the present study was greater than that reported in other studies. This may be attributed to a higher number of cases progressing to non-union in the unreamed group when compared to the reamed group . In a study conducted by Larsen LB et al. involving 45 patients, the average union time in the reamed group was 16.7 weeks, while that in the unreamed group was 25.7 weeks (28). In another prospective randomized study by Gaebler C et al., the mean union time was 17 weeks in the reamed group and 19 weeks in the unreamed group (29). Elbukari et al. reported an average union time of 15 weeks in their study, whereas Akhtar et al. reported an average union time of 23 weeks when compound tibial diaphyseal fractures were treated using unreamed interlocking nails (30). STATISTICAL ANALYSIS OF UNION TIME BETWEEN BOTH GROUPS Null hypothesis: Union is faster in the unreamed group. • Mean union time for the reamed group: 4.5862 months • Standard deviation (reamed group): 0.3171 months • Sample size (reamed group): 29 • Mean union time for the unreamed group: 7.75 months • Standard deviation (unreamed group): 3.6237 months • Sample size (unreamed group): 16 • Calculated t value: −3.4851 • Degrees of freedom: 43 • P value: 0.003 The observed difference in mean union time between the reamed and unreamed groups was statistically significant, thereby rejecting the null hypothesis. Since the p value was less than 0.05, the null hypothesis was rejected, indicating that the reamed group had a significantly lower union time compared to the unreamed group, and this difference was statistically significant. The use of reamed intramedullary nails in open tibial fractures remains controversial. Although reamed nails provide superior mechanical stability, their use carries a theoretical risk of increased non-union and infection due to disruption of the endosteal blood supply . Reamed intramedullary nailing has been shown to be biomechanically more stable; however, it is also associated with drawbacks such as endosteal blood flow compromise, thermal bone necrosis, compartment syndrome, and occasional infection at the fracture site . In contrast, unreamed nailing has not been associated with these biological concerns, but it is considered biomechanically inferior to reamed nailing, and controversy persists regarding its association with implant failure . Previous studies have demonstrated that the risk of non-union in diaphyseal femoral fractures can be significantly reduced with reamed intramedullary nailing compared to unreamed techniques in closed fractures . Extrapolating these findings, it is possible that the risk of non-union in open tibial fractures may also be lower with reamed intramedullary nailing when compared to unreamed nailing; however, further evidence is required to conclusively establish this. Anwar et al. reported that both reamed and unreamed intramedullary nailing of femoral shaft fractures may be associated with pulmonary complications, including pneumonia, acute respiratory distress syndrome, and respiratory failure (32). Pulmonary complications were observed in 19.5% of patients treated with reamed nailing and 9.6% of those treated with unreamed nailing. However, due to the small sample size and limited statistical power, definitive conclusions could not be drawn. According to Duda et al., unreamed nailing of distal tibial fractures results in extremely low axial strain and high shear strain, suggesting that unreamed nailing should be used cautiously in distal tibial fractures unless there is adequate fragment contact or stabilization of the fibula (33). Richter et al. were among the first to focus specifically on unreamed nailing in distal tibial fractures. In their prospective study involving 50 fractures, including 18 with articular involvement of the distal tibia, union was achieved in 90% of cases without additional procedures (34). Currently, unreamed intramedullary nailing is considered the standard of care for Gustilo–Anderson type I, II, and IIIA open tibial fractures presenting within 6–8 hours of injury, with reported advantages over reamed nailing . Experimental studies have shown that unreamed nailing causes less reduction in cortical circulation compared to medullary canal reaming . Klein et al. demonstrated a 31% reduction in cortical circulation with unreamed nailing compared to a 71% reduction following reaming (36). It has also been reported that reaming in open fractures may dislodge small bone fragments from their soft tissue attachments and disseminate contamination from the open wound throughout the medullary canal . Hollow nails have approximately twice the surface area of solid nails, resulting in increased dead space and a higher risk of infection . A loosely fitted intramedullary nail has been associated with a lower risk of cortical necrosis than a tightly fitted reamed nail . Furthermore, the smooth surface of solid nails may reduce bacterial adherence and thereby lower the risk of infection . Functional outcomes in the present study were assessed using the Johner and Wruhs criteria (37). Outcomes were graded as excellent, good, fair, or poor. In the reamed group, the majority of patients demonstrated excellent outcomes, followed by good, fair, and poor outcomes. In the unreamed group, fewer patients achieved excellent outcomes, with a greater proportion showing good, fair, and poor results. These findings were compared with those of two peer studies. The major complications encountered in the present study included infection, anterior knee pain, non-union, delayed union, and malunion. Anterior knee pain was observed with similar frequency in both groups. In the reamed group, two open fractures and one closed fracture developed infection, and one open fracture treated with reaming progressed to infective non-union, requiring exchange nailing at 18 months. One patient with a closed distal one-fourth both-bone diaphyseal fracture developed malunion in the reamed group, likely due to improper fixation and lack of fibular stabilization. As unreamed nailing was more commonly used for open fractures, a higher incidence of infection was observed in this group. Secondary procedures such as split skin grafting and delayed wound closure were required in these cases. One patient with a closed tibial shaft fracture and a narrow medullary canal developed non-union following unreamed nailing and was managed with dynamization at six weeks followed by bone grafting. Another patient with a compound both-bone fracture treated with an unreamed tibial nail developed non-union and required bone grafting and exchange nailing. Notably, no cases of compartment syndrome were observed in either group. Early immobilization using a plaster slab, adequate limb elevation, and emphasis on active ankle movements may have contributed to the absence of this complication. LIMITATIONS: • Small sample size • The results of the study were assessed using subjective scores and not based on objective assessment • longer duration are required to assess the long term outcome of this procedure. SUMMARY • A total of 45 patients were selected for our study. All of them belonged to the age group of 20-70 • The mean age in our study group was found to be 41 in the reamed group and 40 in the unreamed group • Out of the 45 patients selected fro the study 32 were males and 13 were females • Most tibial shaft fractures occurred along with fibular shaft. All of them were a result of high velocity trauma • There were a total of 30 closed fractures and 15 compound fractures • A total of 12 patients included in the study had other associated injuries excluding fibular fractures • In the reamed group a mean union time period of 4.5 months was noted and in that of the unreamed group a mean of 7.73 months was noted. • Since p value is less than 0.05 we can agree that the reamed group has a lower union time when compared to the unreamed group and it is statistically significant • Most of the unreamed tibial fractures(20) had excellent outcome. Seven of them had good ,one had fair and one poor outcome. Where as in Unreamed nailing two patients had excellent,6 good ,5 fair and 3 poor outcomes The major complications encountered in our study were Infection followed by anterior knee pain ,non union, delayed union and malunion.

Analysis of the clinical and functional outcomes of using reamed or unreamed nails to treat tibia shaft fractures was done on a statistically significant number of cases with tibial diaphysis fractures. Our study reveals that the reamed nailing proved beneficial and impact on the overall outcome is superior to unreamed nailing in closed fractures. There was significant difference among healing time between the reamed and unreamed intramedullary nails in the open and closed tibial fractures. Though there are no clear indications or contraindications for choosing either option, it is better to prefer reamed interlocking nailing in closed fractures and unreamed nailing in compound fractures of Gustillo Anderson type 2 or above.

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