‘Surgical management ofdiaphyseal fracture both bone ...



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE

ANNEXURE - II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

|1. Name of the candidate : and address |DR.VIRAJ.K.SHANBHAG P.G. IN ORTHOPAEDICS ROOM NO.112,|

| |PG & INTERNS HOSTEL FOR MEN, MYSORE MEDICAL COLLEGE, MYSORE-570021 |

|2. Name of the institution : |MYSORE MEDICAL COLLEGE & RESEARCH INSTITUTE MYSORE. |

|3. Course of study and : Subject |POST GRADUATE M.S ORTHOPAEDIC |

|4. Date of admission to course: |20/06/2012 |

|5. Title of topic : |“COMPARATIVE STUDY BETWEEN REAMED AND UNREAMED INTRAMEDULLARY INTERLOCKING |

| |NAILING FOR TIBIAL FRACTURES ” |

|6. Brief resume of the intended work : |

|6.1 Need for the study: |

|As industrialization and urbanisation are progressing year to year, with rapid |

|increase in traffic, incidence of high energy trauma are increasing with the same |

|speed. |

|Tibial diaphyseal fractures are the commonest long bone fractures encountered |

|by most orthopaedic surgeon’s .In an average population there are about 26 tibial |

|diaphyseal fractures per 1 lakh population per year .Males are more commonly |

|affected than females with male incidence being about 41 per 1 lakh per year, and |

|female incidence about 12 per 1 lakh per year. There is a bimodal distribution of tibial |

|fractures with a preponderance of young males. 2. |

|Because one third of the tibial surface is subcutaneous throughout most of its length, open fractures are more in tibia than in any other |

|major long bone. Furthermore the blood supply of tibia is more precarious than that of bones enclosed by heavy muscles. |

|3.Tibial fractures may be associated with compartment syndrome, vascular or |

|neural injury. The presence of hinge joints at the knee and the ankle, allows no |

|adjustment for rotatory deformity after fracture .Because of the high prevalence of |

|complications associated with these fractures, management often is difficult, and the |

|optimum method of treatment remains a subject of controversy. 4 |

|4.Among the various modalities of treatment such as conservative gentle |

|manipulation and use of short leg or long leg cast, open reduction and internal fixation |

|with plates and screws , intra medullary fixation (including Ender pins ,intramedullary |

|nails ,and interlocking intramedullary nails with reaming or without reaming ),and |

|external fixation techniques ,surgeon should be capable of using all these techniques |

|and must weigh advantages and disadvantages of each one and adapt the best possible |

|treatment . The best treatment should be determined by a thoughtful analysis of |

|morphology of the fracture, the amount of energy imparted to the extremity, the |

|mechanical characteristics of the bone, the age and general conditions of the patient |

|and most importantly the status of the soft tissues (the skin, muscle and associated neurologic and vascular structures of the leg). |

|5.Three goals must be met for the successful treatment of open fractures of tibia. |

|The prevention of infection ,the achievement of bony union and the restoration of |

|function .These goals are interdependent and usually are achieved in the chronologic |

|order given .For example failure to prevent infection promotes delayed union or non |

|union and delays functional recovery of the limb. |

|Immobilization in a plaster cast has been used most commonly in the past but |

|it does not always maintain the length of the tibia and it leaves the wound relatively |

|inaccessible. |

|Open reduction and internal fixation with plates and screws has yielded |

|unacceptably high rates of infection. This method may be selected with more |

|severe or local injuries, associated displaced intra articular fractures of knee and |

|ankle. |

|c. External fixation, considered the treatment of choice by many truamatologists, |

|has the disadvantages of the bulky frames and frequent pin track infections, nonunions, |

|malunions. |

|d. The intramedullary nailing locked or unlocked has become an attractive option |

|since image intensifier has made closed intramedullary nailing possible. Nail is a load |

|sharing device and is stiff to both axial and torsional forces. Closed nailing involves |

|least disturbance of soft tissue, fracture hematoma and natural process of bone healing |

|as compared to other forms of internal fixation. |

|Intramedullary nails such as Lottes and Ender nails used without reaming have |

|been employed successfully in the treatment of open tibial fractures and have been associated with low rates of post operative infection |

|.They are however |

|contraindicated for communited fractures as there tends to be shortening or |

|displacement of such fractures around these small nails. |

|The locking of intramedullary nails to the major proximal and distal fragments |

|decreases the prevalence of malunion of communited fractures .Until recently, |

|however all interlocking intramedullary nailing involved reaming, which destroys the |

|blood supply. 12. The rate of infection after treatment of open tibial fractures with |

|intramedullary nailing with reaming has been relatively high, causing most |

|investigators to discourage the use of this technique for grade II and III open tibial |

|fractures. |

|6. Moreover studies have shown that reaming results in |

|Snugly fit nailing improving stability of the fracture site. |

|Larger diameter nail can be introduced |

|Treatment of choice for closed tibal diaphyseal fractures |

|But there chance of marrow content embolization to heart & lungs |

|Theoretical chance of anaemia |

|Increased endosteal vasculature damage. |

|Relatively contraindicated in compound (open) fractures |

|7.Studies have shown that undreamed nailing results in |

|a. low cost |

|b. simple instrumentation |

|c. treatment of choice in open tibial diaphyseal fractures |

|d. small diameter & small transverse distal locking nails has high chance of nail breakage & screw failure |

|e. requires external protection with casts |

|f. prolonged non weight bearing. |

| |

|Hence the need for a comparative study of the results of interlocking |

|intramedullary nailing with & without reaming in the treatment of fractures of the tibial |

|shaft. |

|6.2 REVIEW OF LITERATURE: EVOLUTION OF |

|INTERLOCKING INTRAMEDULLARY NAILS |

|The concept of stabilizing tibial shaft fracture by means of intramedullary technique is an old one. The first reported case of |

|intramedullary nailing was of conquista dores in the 16th century. The Sapnish archives briefly mentions that the Incas and Aztecs used |

|resinous wooden pegs in the medullary canal of long bones for the treatment of non unions. |

|Various material have been used for intramedullary nailing including ivory pegs by Birchers in 1886 and Koining of Germany in 1913. |

|Hoglund used bone instead of ivory pegs in 1947. Metal was first used by Senn, Labotte and Hey Grooves. |

|In the 1930s German Othopaedist Gerhard Kuntscher invented a metallic intramedulary nail for fixation of femoral fractures. |

|In 1937, Rush brothers introduced metal nails, later known as “Rush nail”, which had disadvantage that if offered minimal stability. The |

|current nails in use have evolved mainly from the work of Kuntscher in Germany and the Rush family in the USA. |

|Kuntscher performed the first nailing of subtrochanteric fracture in humans in November 1939. |

|The Biomechanical principles of intramedullary splinting were established by the intramedullary nailing technique introduced by Kuntscher |

|in 1940. |

| |

|Unquestionably, Kuntscher is the father of reamed intramedullary nailing. In 1950 he developed the technique of medullary reaming and |

|closed insertion of an intramedullary nail without exposing the fracture. Kuntscher together with Pohl an instrument maker and |

|metallurgist invested a number of nails of different shapes for intramedullary fixation of a fracture. Improvements in the original |

|designs culminated in his design of cloverleaf cross section of a slotted nail. |

|Kuntscher’s concept of the “detensor” (1969) was the predecessor of the current concepts of interlocking, which considerably extend the |

|indications for intramedullary nailing. |

|Closed intramedually nailing came in Vogue in the 1970s with the advent of the image intensifier. |

|The technique of closed interlocking was popularized by the AO – ASIF during the period 1970 – 75 for the middle third for the femur and |

|tibia. |

|Klemm and Schelmann in 1972, made the interlocking design following which in 1974, Grosse and Kempf from France invented the G.K. |

|interlocking nail. |

|BRIEF HISTORY OF THE CONCERNING TOPIC Hippocrates treatise Medicatrix |

|nature provided early advice on treatment of the tibial fibula fracture. Rest and immobilization of the injured extremity by splinting, |

|with fracture healing to follow in time. |

| |

|In mode times, Bohler recommended preliminary skeletal traction for 1 to 3 weeks for difficult tibia fractures and long leg cast |

|treatment, and approach that yielded satisfactory results. |

| |

|Watson – Jones advocated long leg cast treatment for several months, or until the fracture had healed. His rate of non union was very low,|

|but it was not reported in detail. For example, he did not mention the effect of prolonged cast immobilization on joint motion and muscle |

|atrophy. |

|Early in his career, Charnley produced his classic text closed reduction of common fractures (1961), he meticulously described in detail |

|how to reduce tibia – fibula fractures (making use of the periosteal sleeve) and out lined the limitations of the technique described. He |

|recognized a problem reported recently by others, namely, the problem of the intact fibula, which allows the tibia to drift into varus and|

|increases the incidence of delayed union. The conservative school of treatment flourished for almost three decades until the early|

|1960s, when the swiss Arbeitsgemeinschaftfur Osteosynthesefragen (AO) group advocated open reduction and internal fixation with plating as|

|a primary treatment of both closed and open tibia fractures. Their rationale was that prolonged cast immobilization lead to poor results. |

|Numerous publications in the early 1970s supported the AO approach and documented early recovery. . |

|Sarmiento (1967) almost single – handedly stemmed the tide of open reduction and internal fixation of tibia fractures. He advocated closed|

|reduction and the use of patellar tendon, bearing casts or functional bracing. His treatment of over 500 closed tibia fractures with |

|closed reduction and functional bracing resulted in an almost unbelievable union rate of 99.3%, with 0.7% non union and no cases of |

|infection. In 250 open tibia fractures, union rate of 96%. These results were subsequently replicated by brown and Urban (1969) and |

|others. In 1970 to the early 1980s, the AO approach to fracture treatment was further propagated by the development of creative (hands-on)|

|educational work shops, which greatly enhanced the surgeon’s ability to perform open reduction and internal fixation of tibia fractures. |

|This aggressive surgical approach spread very quickly across North America and challenged the conservative approach to fracture |

|management. Anatomic reduction and rigid internal fixation with early motion were the bywords in this period. |

|In 1974 Nicoll’s, 32 observations in almost 800 tibia fractures, open and closed. He outlined the major factors affecting results. |

|1. Degree initial displacement. |

|2. Fracture communition. & Soft tissue damage. |

|Anderson L.D., et. al., (1974)1 reported a 95% union rate in 250 open and closed fractures treated with pins and plaster method followed |

|at 3-6 weeks by weight bearing in a long leg cast. |

|In 1976, Ruedi, Webb and Allgower, reported 97% excellent and good results in 323 closed fractures treated with DCP the infection rate was|

|less than 1%, 80% of 95 open fractures had good or excellent results. Only 12% had an infection. The patients were kept in bed for 1 week |

|after surgery and they were allowed partial weight bearing (20 kg) until fracture healing. Intramedullary nailing (unreamed nails) for |

|tibia fractures was extensively reported in the United States by Lottes (1974). In the majority of both open and closed tibia fractures |

|cases he achieved excellent results, with a 98% union rate in closed tibia fractures and less than 1% infection. He allowed early weight |

|bearing, and in most cases, post operative cast immobilization was not required. Infection rate in his study was 7.3% of 200 cases. |

|Chapman and Mahoney (1979),achieved a fracture healing rate of over 90% when using the Lottes nail in tibia fractures. The primary draw |

|back of lottes nailing was its limited application to the isthmic position of the tibia (a necessity to achieve fracture stability). |

|Ender nail and other flexible nails have also been used with a high rate of success in closed and type |

|I and II open fractures. Subsequent reports by D’Aubigne et al and others of |

|reamed intramedullary nailing has extended the application of intramedullary |

|nailing to longer portions of the shaft with locked nailing. This even included the distal and proximal thirds of tibia fractures and |

|achieved stability. Studies published in the 1970’s and1980’s by the authors reported |

|unacceptably high infection rates (13.6% to 33%) in small series of open tibial |

|fractures treated with reamed nailing .These reports led to the belief that medullary |

|reaming is contraindicated in open tibial fracture, particularly Gustillo II and III types |

|.Studies of open tibial fractures treated with unreamed Ender pins and Lottes nails |

|during the same time period reported infection rates of 6-7 %. DeBastiani and colleagues (1984)|

|treated 91 closed tibial fractures with the orthofix frame with a 91% union rate an average time of 3.6 months |

|to union. Court – Brown and Hughes (1985) obtained worse results with a static external fixator and believed it |

|led to a higher delayed and non unions rate than other treatment. Pankovich AM., et. al., (1981) reported good |

|results in 36 of 38 fractures with flexible nailing. Ender-type curved pins with medial and lateral |

|entry portals for rotational control of the fracture were used. Stacking of |

|multiple pins exert spring force to resist angulation and rotation. They require a stable fracture configuration and fracture of middle |

|one third are best controlled. |

|Over the years, intramedullary techniques for tibia have evolved from use of |

|Ender pins to interlocking nails of the tibia The |

|author27 in 1983 used the Lottes nails and other authors (1986,1989) in a |

|prospective study used Ender type unreamed nails successfully in the treatment of |

|open tibial fractures and have been associated with lower rates of postoperative |

|infection. They are however, contraindicated for communited fractures, as they tends |

|to shatter and displace such fractures around these small nails. The author28 |

|demonstrated that the insertion of the nail without reaming result |

|in better blood supply than with reaming .This is probably due to the avoidance of embolization in the intracortical blood|

|vessels. This type of embolization might be |

|induced by the pressure generated in front and at the side of the reamer. The author28 obtained |

|good results with interlocked unreamed nailing in open |

|fractures of tibia. |

|The author28 used the solid AO unreamed interlocked tibial rod with good |

|success in severely open fractures. |

|In authors’29 studies, 50 open fractures of the tibial shaft that were treated with |

|debridement and interlocking nailing without reaming were followed for an average |

|of 12 months .Most of the fractures were the results of high energy trauma and 68 % |

|of the fractures wounds were grade III. Forty-eight (96%) of the 50 fractures united at |

|an average of 7 months ,there were no malunions .Four infections (8%) all at the sites |

|of grade III fractures .Locking screws broke in five cases (10%) ,but the breakage did |

|not result in a loss of reduction .Three nails broke ,two at the sites of ununited |

|fractures and one at the site of a healed fracture .These results are comparable with or better |

|than those obtained with other forms of fixation ,including |

|immobilization with a cast , unlocked intramedullary nailing and external fixation |

|The authors reported retrospective review of nonreamed tibial nails compared |

|with external fixation of open tibial fractures. They reported a 49 % incidence of |

|infection with external fixation including pin tract infections and a 2 % incidence of |

|infection with nonreamed tibial nailing. |

|The authors30 in a prospective randomized study compared nonreamed locked |

|intramedullary nails to external fixation (21% versus 11%). They reported a higher |

|incidence of wound problems in the external fixation groups as well as increased |

|incidence of malunion of 24% with external fixation versus 5% with intramedullary nailing. The authors31 from April 1991 to June 1996, 69 |

|open fractures of tibia were |

|primarily treated with unreamed nailing .The distribution of fracture type according to |

|the AO classification and soft tissue injury according to Gustilo were as follows |

|;fracture type ;A-28%,B-52%,C-20%,soft tissue injury ;I-30%,II-28%,IIIA-12%,IIIB- |

|12% ,IIIC-6%..Of the 65fractures assessed 46 (71%) healed within 18 weeks without |

|secondary intervention .There was delayed healing in 3 fractures requiring secondary |

|conversion to reamed nailing .8 fractures (12%) developed pseudoarthrosis of which 5 |

|(8%) healed uneventfully. Deep infections manifested in 4fractures (6%).Three of |

|these infections developed after secondary intervention to treat pseudarthroses .Seven |

|of eight pseudarthroses and three of the four infections healed eventfully .Revision |

|procedures were necessary in 11 patients (17%) to deal with disturbed fracture healing |

|or infection (10reamed nailing procedures ,three cancellous bone grafts ,and one of each of the following |

|;sequestrectomy, fibular osteotomy ,plate fixation ,external |

|fixators ,monorail procedure).The results show that the same infection rates were |

|achieved for the UTN as for the external fixators . The advantages of 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 fixators in the |

|treatment of open fractures with severe soft tissue damage. The use of unreamed nails, compared with external fixators (5 studies, |

|n=396 patients), reduced the risk of reoperation, malunion and superficial infection |

|.Comparison of reamed with unreamed nails showed a reduced risk of reoperation, |

|(two studies, n=132) with the reamed technique .An indirect comparison between |

|reamed nails and external fixators also showed a reduced risk of reoperation (two |

|studies ) when using nails .They have identified compelling evidence that unreamed |

|nails reduced the incidence of reoperation ,superficial infections and malunions ,when |

|compared with external fixators .Relative merits of reamed versus unreamed nails in |

|the treatment of open tibial fractures remain uncertain . |

|6.3. OBJECTIVES OF THE STUDY: 1. To evaluate |

|the results of interlocking intramedullary nailing with & without |

|reaming in the treatment of fractures of the Tibial shaft. |

|2. To study the difficulties (complications) encountered during the operative study. |

|3. To mobilise the patient early. |

|4. To compare the efficacy of interlocking intramedullary nailing with & without reaming in |

|treating fractures of tibia in terms of – |

|a. time required for the union of fracture. |

|b. range of motion of ankle and knee joint. |

|c. rate of malunion and mal rotation |

|d. pain at the knee joint. |

|e. rate of infection & failure of implant |

|7. MATERIALS AND METHODS : |

|7.1 Source of data : |

|The proposed study is a hospital based prospective study centered in K.R.Hospital attached to the Mysore Medical College, Mysore during |

|the term between Sept2012 to June2014 |

|7.2 Method of collection of data (including sampling procedures if any) : |

|Inclusion Criteria |

| |

|Age group adults (>18years) |

|Male and female patients. |

|Radiologically diagnosed tibial shaft fractures(Diaphyseal fractures of the tibia) |

|Consent to participate in the study |

|Exclusion Criteria |

|1. Fractures of the tibial shaft with compartment syndrome needing fasciotomy |

|2.Fractures of the tibial needing vascular repair 3. |

|Fractures associated with distal articular surface of the tibia |

|4. Refusal to provide informed consent 5.Associated systemic co |

|morbidities like Type 2 diabetes , Hypertention. |

|Sampling Procedure:- |

|History |

|Clinical examination |

|Radiological examination |

|7.4 Investigations: |

|Blood : Hb, BT, CT, TC, DC, ESR |

|Blood : RBS, BU, & SC |

|ECG : In all leads |

|HIV, HBSAg |

| |

|Plain radiograph AP and lateral view of affected leg with knee joint & ankle joint. |

|Patients subjected to surgery will be followed up at regular intervals with clinical and radiological data. Assessment will be done based|

|on a proforma containing all necessary information regarding. |

| |

|Personal details age, sex, address and occupation |

|Type of fracture |

|Surgical procedure carried out |

|Duration of hospital stay |

|Initiation of mobilization |

|Physiotherapy |

|Development of surgical complications |

|Postoperative Evaluation |

|The results will be evaluated with the help of following parametres |

|a. time required for the union of fracture. |

|b. range of motion of ankle and knee joint. |

|c. rate of malunion and mal rotation |

|d. pain at the knee joint. |

|e. rate of infection. |

|f. failure of the implant. |

| |

|7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please |

|describe briefly. |

|NO |

| |

|7.4 Has Ethical clearance been obtained from your institution? |

|YES , Copy enclosed |

| |

|. |

|8. LIST OF REFERENCES : |

|1) Bucholz and Heckman’s ROCKWOOD GREENS: FRACTURES IN |

|ADULTS,Vol 2:5th edition 2001 ,Lipincott Williums and Wilkins |

|Company,USA,pages 1939-1994. |

|2) Terry Canale’s CAMPBELL’S OPERATIVE ORTHOPAEDICS Vol 3,10th |

|edition, 2003.Mosby publishers, pages 2754-2782. |

|3) Nicoll EA, 1964: “fractures of the tibial shaft; a survey of 705 cases”. J Bone |

|Joint Surg, 46B:373-387. |

|4) Watson –Jones:”Injuries of the leg “. Chapter-32in Watson Jones fractures and |

|joint injuries “6th Edn,Wilson JN (Ed), B.I.Churchill Livingstone , New Delhi |

|,1998, 387pp. |

|5) Brown PW,Urban JG,1969: “early weight bearing treatment of open fractures |

|of the tibia : An end result of ………. : J Bone Jiont Surg ,51A:59-75. |

|6) Bach AW,and Hansen Jr.ST,1989:“Plates versus external fixation in severe open |

|tibia shaft fractures: A randomised study: Clin Orthop: 241:89-94. |

|7) Ruedi T, Webb JK, and Allgoer M, 1976: “experience with the dynamic |

|compression plate (DCP) in 418 recent fractures of tibial shaft ’’ Injury, 7:252- |

|257. |

|8) Smith JE 1974:”Results of early and delayed internal fixation for tibial shaft |

|fractures: A review of 470 fractures “.J Bone Joint Surgery (Br), 56-B 469-477. |

|9) Holbrook JL,Swiontiowski MF,Sanders R 1989: “treatment of open fractures of the tibial shaft: Ender nailing |

|versus external fixation ; a randomised prospective |

|comparison”. J Bone Joint Surg, 71A:1231-1238. |

|10) Charley J, “tractures of the shaft of tibia” .the closed treatment of common |

|fractures, Edinburg, Churchill Livingstone, 1961:209-249pp. 11) Swanson |

|TV,Speigel JD,Sutherland TB, Bray TJ,Chapman MW , 1990:”A |

|prospective , comparative study of the Lottes nail versus external fixation in 100 |

|open tibial fractures”. Orthop Trans .14: 716-717. |

|12) Rhinelander FW, 1974: “tibial blood supply in relation to fracture healing”. Clin |

|Orthop, 105:34-81. |

|13) Gustilo RB,:”fractures of the tibia and fibula” .chapter -27 ,fractures and |

|dislocations ,edt.Gustllo RB,Kyle RF,and Templemen DC,Mosby |

|Philadelphia,1992:901pp. |

|14) Watson Jones R, Coltart WD, 1942: “Slow union of fractures with a study of 804 |

|fractures of the shaft of the tibia and femur “. J Bone Joint Surgery,30:260 |

|15) Dehne E,Metzcw,Deffer PA,et al ,1961: nonoperative treatment of the fractured |

|tibia by immediate weight bearing .J Trauma,1:514. |

|16) Sermiento A, 1967:”Functional below knee cast for tibial fractures “.J Bone Joint |

|Surg (Am), 49:855. |

|17) Burwell HN, 1971: “plate fixation of tibial shaft fractures – A survey of 181 |

|injuries”, J Bone Jiont Surg (Br), 53:258. |

|18) Anderson LD,Hutchens WC,Wright PE,and Disney JM,1974: |

|“Fractures of the tibia and fistuls treated by casts and transfixing pins ’’Clin |

|Orthop, 105:179-191. |

|19) Ruedi T, Webb JK, and Allgoer M, 1976: “experience with the dynamic |

|compression plate (DCP) in 418 recent fractures of tibial shaft ’’ Injury, 7:252- |

|257. |

|20) Lottes JO., 1974:’’Medullary nailing of the tibia with the triflange nail’’. Clin Orthop,: 21) Chapman MW,Mahoney M,1979: the role |

|of internal fixation in the management |

|of open fractures ” .Clin orthop ,138: 120-131. |

|22) Bone LB, Johnson KD, 1989: “treatment of tibial fractures by reaming and |

|intramedullary nailing” .J Bone Jiont Surg (Am), 68:877-887. |

|23) Chapman MW ,1986: “the role in intramedullary fixation in open fractues” .Clin |

|Orthop ,212:26-34 |

|24) Court Brown CM,and Hughes SPF,1085:”hghes external fixator in treatment of |

|tibial fractures ” .J Soc Med ,78:830-87 |

|25) DeBastiani G, Aldegheri R, and Renzi Brivo l, 1984:”the treatment of fractures |

|With dynamic axial fixators” .J Bone Joint Surg: 66:538-545. |

|26) Pankovich AM, Tarabisky IE,and Yelda S,1981: “flexible intramedullary nailing |

|of tibial shaft fracture”. Clin Orthop, 160:185-195. |

|27) Velasco A,White-SideTE. Jr and Fleming LL, 1983:”Open fractures of the tibia |

|treated with the Lottes nail”.J Bone Joint Surg(Am),65:879-885. |

|28)Weller S, and Hontsch .D:”Medullary nailing of femur and tibia “. Chapter -4 in |

|“Manual of internal fixation ,techniques recommended by the AO/ASIF group ” |

|,3rd edn,muller ME,Allogwer M,(Ed),Spinger-Verlag, Newyork ,1998,2067- |

|2094pp. |

|29) Whittle AP,Russell TA,Taylor JC,Lavelle DG,1992 : “treatment o open fractures |

|of the tibial shaft with the use of interlocking nailing without reaming ’’ .J Bone Joint Surg, |

|74A:1162-1171 |

|30) Henley MB,Chapman JR ,Agel J ,et al ,1994: “comparision treatment of grade II |

|and III open tibial shaft fractures ”. Orthop trans ,19:143-144. |

| |

| |

| | |

|9. Signature of the candidate : |Dr.VIRAJ.K.SHANBHAG |

|10. Remarks of the guide : | |

| | |

| | |

|11.Name and designation of (in |Dr.KIRAN KALAIAH |

|block letter) |Professor , Department of Orthopedics |

|11.1 Guide |K.R. Hospital, Mysore Medical College & Research Institute, Mysore. |

|11.2 Signature of guide: | |

|11.3 Co-Guide (if any) | |

|11.4 Signature of co-guide: | |

|11.5 Head of Department |Dr.KALADAGI.P.S |

| |Professor & HOD, Department of Orthopedics |

| |K.R. Hospital Mysore Medical College, Mysore. |

|11.6 Signature of HOD |

|12. Remarks : |

|12.1 Remarks of Dean & Director: |

|12.2 Signature : |

ETHICAL COMMITTEE CLEARANCE

1.Title of dissertation : COMPARATIVE STUDY

BETWEEN REAMED AND

UNREAMED INTRAMEDULARY

INTERLOCKING NAILING FOR

TIBIAL FRACTURES

2. Subject : M.S. ORTHOPAEDICS

3. Name of the Candidate : DR.VIRAJ.K.SHANBHAG

4. Name of the Guide : DR.KIRAN KALAIAH

M.S(ORTHO)

Professor

Department of Orthopaedics

Mysore Medical College &

Research Institute, Mysore.

5. Approved / not approved

(If not approved, suggestions) :

MEMBERS OF THE ETHICAL CLEARANCE COMMITTEE

PROFESSOR & HOD PROFESSOR & HOD

DEPARTMENT OF SURGERY DEPARTMENT OF MEDICINE,

MYSORE MEDICAL COLLEGE & MYSORE MEDICAL COLLEGE &

RESEARCH INSTITUTE, RESEARCH INSTITUTE,

MYSORE MYSORE

MEDICAL SUPERINTENDENT MEDICAL SUPERINTENDENT

K. R. HOSPITAL CHELUVAMBA HOSPITAL

MYSORE MYSORE

MEDICAL SUPERINTENDENT LAW EXPERT

PKTB HOSPITAL

MYSORE

DEAN AND DIRECTOR ,

MYSORE MEDICAL COLLEGE & RESEARCH INSTITUTE MYSORE.

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