Intramedullary nailing in the management of distal tibial fractures

Optimal use of transmedullary support screws and fibular management in distal tibial fracture nailing based on a new biomechanical classification

INTRODUCTION

Based on a novel simple frontal view classification, a comprehensive concept for systematic management of intramedullary fixation of distal tibial fractures is introduced. Even the usage of thin (unreamed) nails allows for anatomic reduction and stable fixation if applied in combination with transmedullary support (TMS) screws. Our classification system guides the placement of the TMS screw (medial or lateral) and suggests whether to fix the fibula or not.

PATIENTS AND METHODS

The fixation concept of the classification was applied to 67 distal tibial fracture cases. Patients were followed up until nail removal after at least 12 months.

RESULTS

All fractures united. Besides 5 cases of slight external malrotation (<5 degrees) no axial malunion was found. Two infections were encountered, but both were treated effectively by exchange nailing, antibiotic therapy until wound healing and C-reactive protein normalization. Final functional assessment according to Olerud/Molander Score was 85 pts (100 pts. possible, range 50-100 pts).

DISCUSSION

The stability we achieved even with single screw interlocking was high due to anatomic reduction with interfragmental compression in the lowest fracture line. In cases of fracture extension into the ankle joint, interfragmental compression screws were applied before nail insertion. In more comminuted fracture types additional screws are advisable.

CONCLUSIONS

The frontal view classification has proven to be a reliable guideline for effective intramedullary fracture fixation by minimally invasive means, allowing for optimized soft tissue protection.

Extra-articular distal tibial fractures, is interlocking nailing an option? A prospective study of 147 cases

PURPOSE

Distal tibia fractures comprise about 7%-10% of lower extremity trauma. Because of the peculiarity of the soft tissue and subcutaneous location of the bone there are many controversies in the ideal treatment of distal tibia fractures especially extra articular pilon fractures. Plating is fraught with complications of wound dehiscence and infection. There are limited studies which document outcomes in such cases using intramedullary interlocking nail. We intend to study the outcome and complications of extra articular distal tibial fractures treated with interlocking nailing.

METHODS

This is a prospective study conducted in a tertiary care orthopaedic hospital in southern India. There are 147 patients of distal tibia extra-articular fractures managed by IM nailing with follow up of more than one year were included in this study. Only cases with fresh injury (less than 1 week), fracture below the isthmus, closed and open Gustilo Anderson type 1 and 2 fractures were included in the study. Patients were reviewed at 3, 6, 12 and 24 weeks after surgery and thereafter at one year and were assessed for clinical and radiological signs of healing, any complications, time to union and functional outcome.

RESULTS

There were 102 males and 45 females (male/female ratio is 2.3:1) with a mean age of 38.96 (range 23-65) years. According to AO classification, there were 78 cases (53.06%) of 43-A1, 39 cases (26.53%) of 43-A2 and 30 cases of 43-A3 constituting 20.40%. The fracture united in all the patients at an average of 18 weeks (range 16-22 weeks), none of the patient in our series had a delayed or non-union. Two patients (1.47%) had the fracture united in mild valgus but it was well within the acceptable limits (<5°). The functional outcome was assessed in all the patients at final follow up using Olerud and Molander score all the patients fared an excellent to good score, there were no cases with poor score.

CONCLUSION

Intramedullary nailing is a viable option to treat distal tibial fractures with excellent outcome. Wound complications related to plating can be avoided but meticulous surgical technique is key to avoid malunion.

Comparison of low, multidirectional locked nailing and plating in the treatment of distal tibial metadiaphyseal fractures

PURPOSE

The aim of this study was to compare the results of a new technique for low, multidirectional locked nailing with closed reduction and minimally invasive plating in the treatment of distal tibial metadiaphyseal fractures.

METHODS

Forty-six matched patients were divided according to age, gender, Injury Severity Score, and fracture pattern into group A (expert tibial nailing) and group B (minimally invasive plating). Then, the patients were followed up, and the clinical and radiographic results were retrospectively analysed.

RESULTS

The mean followed-up was 24.7±2.7 months in group A and 25.8±2.8 months in group B. No patient had nonunion, shortening, hardware breakdown, or deep-seated infection. Patients in group A had a significantly shorter mean operating time, hospital stay, full weight-bearing time and union time (76±16.6 vs. 90±20.3 minutes, p=0.000; 5.8±2.1 vs. 8.9±3.1 days, p=0.000; 9.0±1.4 vs. 11.1±1.7 weeks, p=0.000; and 21.3±3.5 vs. 23.1±3.6 weeks, p=0.047, respectively). Three patients in group A and one patient in group B presented with malalignment (p=0.608). The mean Olerud-Molander Ankle score was 89.0±7.1 in group A and 87.6±8.4 in group B (p=0.478).

CONCLUSIONS

Distal tibia metadiaphyseal fractures may be treated successfully with low, multidirectional locked nails or plates. However, low, multidirectional locked nailing may represent a superior surgical option, since it offers advantages in terms of mean operating time, hospital stay, full weight-bearing time and union time.

Distal quarter leg fractures fixation: The intramedullary nailing alone option

INTRODUCTION

Intramedullary (IM) nailing is the classical treatment for diaphyseal fractures of the tibia. Stabilizing fractures of the distal quarter is recognized as being delicate. We report a continuous, multicenter prospective study of distal tibia-fibula fractures treated with anterograde intramedullary nailing.

HYPOTHESIS

The working hypothesis was to identify the problems encountered with IM nailing alone of distal leg fractures.

PATIENTS AND METHODS

From May 2007 to November 2008, 51 fractures in 51 patients (19 females and 32 males; mean age, 46.2 years [range, 17-93 years]) were treated with IM nailing. The fractures were classified according to the association pour l'ostéosynthèse (AO) classification, with most type A1 (29/51). Thirteen fractures presented a distal articular extension treated with screws in five cases. Fixation consisted in intramedullary nailing, reamed in all cases, performed on a standard or orthopaedic surgery table. Nailing was static and distally locked (50/51). The patients were evaluated clinically and radiologically, with AP and lateral images of both legs and the Olerud score.

RESULTS

We report one death and eight patients lost to follow-up, providing 42 cases to reviewing at 1 year. The bone union rate was 97.6% in a mean 15.7 weeks. Immediately after surgery, 14 axial deviations greater than 5° were observed, mainly valgus, with only one greater than 10°. The absence of fibular fixation was the only identifiable risk factor for appearance of an initial axial deviation as well as fracture instability over time. Two infections were observed and at 6 months four secondary displacements, one of which can be explained by changing the distal locking due to infection. Four dynamizations were performed. No other risk factor was found. The mean Olerud functional score at 12 months was 83.5 points.

DISCUSSION

The clinical results are comparable to those reported in the literature. From a radiological point of view, the rates and times to bone union were identical. However, the rates of malunion were clearly higher. The risk factors for malunion found in the literature are metaphyseal enlargement, fracture comminution, a too distal location of fracture site, young patient age, patient installation on a standard operating table, and technical errors. The absence of supplementary fibular fixation, the subject of debate in the literature, was the only statistically significant point found in the present study. Nailing distal fractures of the leg provides good clinical results. However, with regard to the malunion rates, the technique must be precise and rigorous. We recommend systematic fibular fixation and use of an orthopaedic table.

LEVEL OF EVIDENCE

Level IV; cohort type prospective study.