Current Evidence: Plate Versus Intramedullary Nail for Fixation of Distal Tibia Fractures in 2016

Preliminary results of stabilization of far distal tibia fractures with the distal tibial nail: A prospective, multicenter case series study

INTRODUCTION

The distal tibial nail (DTN) is a novel retrograde intramedullary nail used for distal tibial fracture stabilization. We investigated the clinical results of DTN use for distal tibial fractures and compared them with those reported in the literature on locking plates and antegrade intramedullary nails.

MATERIALS AND METHODS

This multicenter, prospective, observational cohort study examined distal tibial fractures with AO/OTA classification 43 types: A1, A2, A3 or C1. The primary outcomes included bone union rate, soft tissue problems, and surgical complications. Secondary outcomes were EuroQol-5 Dimension-5 Level (EQ-5D-5L), Self-Administered Foot Evaluation Questionnaire (SAFE-Q), and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot clinical scores 1 year postoperatively. Incidence of varus or valgus/anterior-posterior flexion deformity with a difference of ≥5° and postoperative reduction loss rate were evaluated.

RESULTS

Five men and five women were enrolled (mean age, 69 years [range, 30-77 years]), including one open-fracture-type Gustilo type IIIB case. Bone union was observed in all patients at 6 months postoperatively. Delayed union, leg edema, and guide pin breakage were observed in three, one, and one cases, respectively. No soft tissue or surgical complications were observed. During the final follow-up, the EQ-5D-5L, SAFE-Q, and AOFAS hindfoot scores were 0.876 (0.665-1.0), 83-92, and AOFAS 92.6 (76-100), respectively. Varus and retroflexion deformities were observed in one case each.

DISCUSSION

DTN has been reported to have biomechanically equivalent or stronger fixation strength than locking plates or antegrade intramedullary nails. In addition, while DTN was thought to be less invasive for soft tissue and can avoid injury to the knee, it was thought that care should be taken to avoid medial malleolus fractures and posterior tibialis tendon injuries. Comparisons with literature treatment results for locking plates and antegrade intramedullary nails showed comparable to advantageous results.

CONCLUSIONS

DTN treatment results for distal tibial fractures were as good as those for locking plates and antegrade intramedullary nails. DTN is useful for stabilization and does not compromise the surrounding soft tissues.

Outcomes and their predictors in suprapatellar nailing for tibia fractures. Multivariable analysis of 293 consecutive cases

PURPOSE

Intramedullary nailing of tibial fractures is one of the most common procedures in orthopedic surgery. It can be technically demanding in proximal or distal fractures, which may be facilitated using semi-extended approaches. The aim of this study is to identify outcomes and their predictors using a semi-extended suprapatellar approach for tibial fracture nailing.

METHODS

This is a retrospective cohort of 293 patients who underwent intramedullary nail fixation of a tibial fracture through a suprapatellar approach, considering a postoperative follow-up of 1 year. Data on patient's baseline characteristics, injuries, treatments, and outcomes regarding alignment, fracture union, and complications were recorded. For multivariable analysis, hierarchical binary (logistic) regression analysis was performed.

RESULTS

The mean patient age was 47.7 years (SD 18.9), with 42A1 the most frequent fracture pattern (n = 98, 33.5%). Correct or anatomical alignment (≤ 5º in both planes) was achieved in 272 (92.8%) of the patients. On multivariate analysis, surgical delay ≥ 7 days (OR = 1.3, 95% CI = 1.3-8.1) and age over 50 years (OR = 3.2, 95% CI = 1.2-8.3) were found as predictors of fracture malalignment. Fracture healing was achieved in 97.6%, and reoperation rate was 6.14%. Overall complication's predictors were proximal fracture (OR = 2.8, 95% CI = 1.1-7.2), temporary external fixation (OR = 2.4, 95% CI = 1.2-4.9), and fracture malalignment (OR = 2.9, 95% CI = 1.1-7.9).

CONCLUSION

The suprapatellar approach is a safe and useful technique for treating tibial fractures, leading to no less than correct reduction in almost all patients and achieving a high fracture healing rate, at very low rates of complications. Pre- and postoperative predictors identified must be taken into account to improve outcomes while treating these fractures.

Wound infection and healing in minimally invasive plate osteosynthesis compared with intramedullary nail for distal tibial fractures: A meta-analysis

To systematically explore the effects of minimally invasive plate osteosynthesis (MIPO) versus intramedullary nail (IMN) on wound infection and wound healing in patients with distal tibia fractures. A computerised search of PubMed, Web of Science, Cochrane Library, Embase, Wanfang, China Biomedical Literature Database (CBM) and China National Knowledge Infrastructure databases was performed, from their inception to October 2023, to identify relevant studies on the application of MIPO and IMN in patients with distal tibial fractures. The quality of the included literature was evaluated by two researchers based on inclusion and exclusion criteria, and basic information of the literature was collected, with wound infection, postoperative complications and wound healing time as the main indicators for analysis. Stata 17.0 software was applied for analysis. Overall, 23 papers and 2099 patients were included, including 1026 patients in the MIPO group and 1073 patients in the IMN group. The results revealed, when compared with IMN treatment, patients with distal tibia fractures who underwent MIPO treatment had a lower incidence of postoperative complications (OR = 0.33, 95% CI: 0.25-0.42, p < 0.001) and a shorter wound healing time (SMD = -1.00, 95% CI: -1.51 to -0.49, p < 0.001), but the incidence of postoperative wound infection was higher (OR = 2.01, 95% CI: 1.35-3.01, p = 0.001). Both MIPO and IMN are excellent treatments for distal tibia fractures. MIPO is effective in reducing the incidence of complications as well as shortening the time of wound healing time but increases the risk of wound infection. In clinical practice, surgeons can make individual choices based on the patient's wishes and proficiency in both techniques.

Early results of intramedullary nail fixation in distal tibia oblique osteotomy for the reduction of soft tissue complications

PURPOSE

During distal tibial oblique osteotomy, external fixators can increase pin site infection risk, whereas plates can cause wound necrosis, necessitating a compromise between soft-tissue position and length. We provide the first report of the early results of intramedullary nail fixation in these osteotomies for avoiding soft tissue complications.

METHODS

Ten ankles, classed as Takakura-Tanaka stages 3a to 4 and unclassified and treated via distal tibial oblique osteotomy for ankle osteoarthritis between 2017 and 2021, were included. Osteotomy was performed obliquely from the distal medial tibia to the tibiofibular joint. The distal tibial fragment was rotated distally in the coronal plane for realignment. An intramedullary nail fixation was applied for stabilization. The resulting gap was filled with iliac bone graft. Ankles were evaluated on the Japanese Society for Surgery of the Foot ankle-Hindfoot Scale and Self-Administered Foot Evaluation Questionnaire before surgery and at final follow-up. Radiographic assessments were performed.

RESULTS

Bone union was achieved within 3 months in all patients. There were no cases of wound necrosis or correction loss postsurgery. Japanese Society scale scores significantly improved from 40.3 ± 15.9 to 87.5 ± 12.6 (P < 0.01). Mean self-evaluation scale scores (pain and pain-related, physical functioning and daily living, social functioning, general health and well-being) improved significantly. shoe-related scores did not change significantly but improved. There was no correction loss after surgery, with an average widening of 24.2 mm and opening angle of 22.6° at the osteotomy site.

CONCLUSION

Our study showed that intramedullary nail for fixation of the osteotomy site in distal tibial oblique osteotomy effectively prevents soft tissues complications even in osteotomy sites with large openings.

Are pre- and postoperative true translational and angular displacement predictive of nonunion after intramedullary nail fixation of tibial shaft fractures?

PURPOSE

To determine if there is an association between pre-/postoperative translational and angular displacement with nonunion after intramedullary nail (IMN) fixation of tibial shaft fractures.

METHODS

Retrospective review of 120 patients with tibial shaft fractures undergoing IMN at an urban level-one trauma center was performed. Demographics, injury characteristics, and pre-/postoperative translational and angular fracture displacement in the coronal and sagittal planes were recorded. True fracture translational and angular displacement (TTD and TAD) were calculated by combining sagittal and coronal displacement utilizing the Pythagorean theorem.

RESULTS

10.8% of patients (n = 13) developed nonunion with remaining patients serving as the control. Groups were similar across age, sex, and BMI. Univariate analysis revealed no difference in pre-/postoperative TAD between nonunion and union groups and an increased preoperative TTD (median difference (MD): 6.2 mm, CI: 1.4-10.8 mm) and postoperative TTD (MD: 1.8 mm, CI: 0-3.7 mm) in the nonunion group. On multivariate analysis, however, only tobacco use and type 2 or 3 open fractures were associated with nonunion (OR: 5.1, CI: 1.2-22.8 and OR: 4.9, CI: 1.2-19.2, respectively).

CONCLUSION

True translational and angular displacement of tibial shaft fractures before and after IMN fixation were not independently associated with nonunion. Tobacco use and type 2 or 3 open fracture are independent factors for nonunion.

The semi-extended infrapatellar intramedullary nailing of distal tibia fractures: a randomized clinical trial

BACKGROUND

Malalignment is a common event during the intramedullary nailing (IMN) of distal tibia fractures (DTFs). Although it is reported that the semi-extended IMN techniques such as suprapatellar (SP) and parapatellar (PP) approaches may be superior in preventing malalignment, the application of these techniques is concerning owing to the intra-articular involvement. We thus developed an extra-articular semi-extended infrapatellar (SEIP) approach which utilizes the infrapatellar (IP) space while maintaining the knee in a semi-extended position. However, there are no studies on the safety and efficacy of SEIP in treating DTFs. Therefore, in this study, the SEIP technique was examined, particularly in terms of the potential alignment improvement of DTFs, and this technique was compared with the traditional hyperflexed infrapatellar (HFIP) procedure.

MATERIALS AND METHODS

This randomized clinical trial (RCT) compared IMN malalignment while correcting extraarticular and nondisplaced intra-articular DTFs between April 2018 and June 2021 using the HFIP and SEIP techniques at a level I trauma center in China. The study participants were clinically and radiographically examined for at least 12 months of follow-ups. Intraoperative fluoroscopy time, operation time, blood loss, hospitalization duration, functional ankle score, and complications were assessed as well.

RESULTS

Among the 88 recruited participants, 45 (51%) underwent traditional HFIP IMN and 43 (49%) underwent SEIP IMN. Malalignment occurred in 9 patients (20.0%) from the HFIP cohort and in 2 patients (4.7%) from the SEIP cohort (P value = 0.030). In addition, the SEIP IMN technique significantly reduced the intraoperative fluoroscopy time, operation time, and improved the postoperative ankle function compared to the HFIP IMN technique. However, the intraoperative blood loss, hospitalization duration, infection, delay union, and nonunion remained the same between the two cohorts.

CONCLUSIONS

In summary, we demonstrated that the SEIP IMN provides markedly enhanced alignment of extraarticular and nondisplaced intra-articular DTFs compared to the traditional HFIP IMN procedure. The described technique represents an effective option for IMN of DTFs.

LEVEL OF EVIDENCE

Level 2. Trial registration The Chinese Clinical Trial Registry, ChiCTR2100043673. Registered 26 February 2021, retrospectively registered, http://www.chictr.org.cn/showprojen.aspx?proj=122263.

Preoperative and Intraoperative Considerations Using Intramedullary Nails for the Treatment of Tibial Shaft Fractures Below Total Knee Arthroplasty

SUMMARY

Periprosthetic tibial shaft fractures below total knee arthroplasty (TKA) are relatively rare, with an incidence of approximately 1%. However, as the rates of arthroplasty increase, orthopaedic surgeons are likely to see a corresponding increase in these types of fractures. Native tibial shaft fractures are routinely treated with either nails or plates, and the success of intramedullary nailing of tibial shaft fractures has been well described in the literature. In this article, we seek to describe a case series of tibial shaft fractures in patients with ipsilateral TKA treated with infrapatellar intramedullary nailing. We will focus on preoperative considerations including templating and measurement of the anterior cortical implant distance on the lateral radiograph to ensure space for safe nail passage. We will also discuss intraoperative technical tricks, including Kirschner wire insertion for sounding the start point, utilization of the curved awl, use of hand reamers, and rotation of the nail to bypass the implant. Using meticulous preoperative planning and technical intraoperative tricks, patients with tibial shaft fractures below TKA may be successfully treated with intramedullary nailing.

Extreme nailing and immediate weight bearing constructs in fractures of the distal tibia

Extraarticular fractures of the distal tibia can present as difficult but manageable lower extremity injuries. Historically, these injuries have been fixed in a myriad of ways. Early management with intramedullary nailing had higher complication rates due to the unique anatomical and biomechanical features of the distal tibia. Modern improvements in intramedullary nailing surgical techniques and implant design have significantly decreased complication rates and led to improvement in patient outcomes. Many surgeons protect weight bearing postoperatively, but recent literature suggests that patients may safely weight bear immediately following intramedullary fixation. This article reviews technique and implant design changes that have facilitated immediate safe weight bearing following intramedullary nailing of extraarticular distal tibia fractures.

A novel intramedullary nail to control interfragmentary motion in diaphyseal tibial fractures

Numerous animal and human studies have demonstrated the benefit of controlled interfragmentary motion on fracture healing. In this study, we quantified interfragmentary motion and load transfer in tibial fractures fixed using a novel intramedullary nail (IMN) that allows controlled axial motion. Fifty composite tibias with various fracture patterns were utilized. For all test conditions, two interlocking screws were used to fix the nail in the proximal metaphysis, and two interlocking screws through the distal metaphysis. The nail allowed either no motion (static mode) or 1 mm (dynamic mode) of cyclic axial motion between the two fracture fragments for every fracture pattern tested. As expected, strain shielding was more prominent under static nail conditions. In contrast, specimens tested under dynamic nail conditions transferred axial load between the fracture fragments such that strains near the fracture site were generally similar to those measured on an intact tibia. Maximum shear strains proximal to the fracture were significantly lower in specimens with oblique or butterfly fracture patterns (p < 0.01) compared to intact specimens. This decrease in shear strain indicates that strain shielding effects were likely present due to the implant. However, strain shielding appeared to be reduced in tensile and compressive principal strains. In summary, the novel IMN allowed controlled axial motion between the fragments in a variety of common diaphyseal tibial fracture patterns. Clinical Significance: The present in vitro biomechanical study investigated a novel intramedullary nail capable of controlled axial interfragmentary motion which may potentially enhance fracture healing.

MIPO vs. intra-medullary nailing for extra-articular distal tibia fractures and the efficacy of intra-operative alignment control: a retrospective cohort of 135 patients

INTRODUCTION

Definitive treatment of distal extra-articular fractures of the tibia is challenging and both minimal invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are considered to be feasible surgical modalities with their own implant-specific merits and demerits. This retrospective study was designed to compare MIPO versus IMN in terms of fracture healing, complications, functional and radiological outcomes and to assess the efficacy of intra-operative alignment control to reduce the rate of malalignment after definitive fixation of distal extra-articular fractures of the tibia.

MATERIALS AND METHODS

All consecutive adult patients with extra-articular distal meta- or diaphyseal tibia fractures that were treated between January 2012 and September 2019 either with MIPO or IMN were included. Outcome measures included fracture healing, complications (infection, malalignment, subsequent surgeries), functional and radiological outcomes. Intra-operative alignment control encompassed bilateral draping of the lower extremities.

RESULTS

A total of 135 patients were included out of which 72 patients (53%) were treated with MIPO and 63 patients (47%) underwent IMN. There was a significantly higher incidence of non-union for fractures treated with IMN (13 (22%) vs. 4 (6%), p = 0.04). There was no significant difference between both groups in terms of rotational malalignment (3% vs. 10%) and angular malalignment (4% vs. 5%). A significantly higher rate of infection was found after MIPO after correction of significant differences in baseline characteristics. No differences were found in subsequent surgeries or functional outcomes.

CONCLUSION

Both MIPO and IMN are reliable surgical techniques. IMN is associated with higher rates of non-union, whereas MIPO results in a higher risk for infection. The incidence of malalignment was surprisingly low endorsing the utility of the intra-operative alignment control.

How the Choice of Osteosynthesis Affects the Complication Rate of Intercalary Allograft Reconstruction? A Systematic Review and Meta-analysis

BACKGROUND

There is no clear consensus on the optimal type of fixation in intercalary allograft reconstruction. In this study, we aimed to compare the rate of most common complications following the plate and nail fixation of the intercalary allograft.

MATERIALS AND METHODS

We searched PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library. Studies in which the complication rate of the single bridging plate and intramedullary nail fixation was extractable were included. Studies that used extra procedures such as cementation and fibular vascular graft augmentation were excluded. The primary outcome was the fixation-specific rate of nonunion. Secondary outcomes were the fixation-specific rate of fracture, infection, and local recurrence.

RESULTS

In total, 13 studies with 431 reconstructions (352 reconstructions in the plate group and 79 reconstructions in the intramedullary nailing group) were included in this study. In the plate fixation, the rate of nonunion, fracture, infection and local recurrence was 12%, 11%, 11%, and 3%, respectively. In the intramedullary nail fixation, the rate of nonunion, fracture, infection, and local recurrence was 37%, 5%, 4%, and 0%, respectively. The rate of nonunion was significantly higher in the intramedullary nail group (OR = 6.34; 95% CI 2.98-13.49, P < 0.001). The rate of fracture, infection, and local recurrence was not significantly different between the two fixation methods.

CONCLUSIONS

Intramedullary nail is associated with a significantly higher rate of nonunion. Since the rate of other complications was not significantly different between the two osteosynthesis types, plate fixation could be considered as a better type of fixation.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00563-7.

A New Technique for Placement of Blocking Screws and its Mechanical Effect on Stability of Tibia Fractures with Distal Fragments after Insertion of Small-Diameter Intramedullary Nails

Objective

To design a novel blocking screws (BSs) geometry and insertion method to treat distal tibia fracture with nailing and comparison of mechanical properties of novel and traditional screws.

Methods

Twenty‐one synthetic left tibiae were sectioned to obtain 21 distal segments measuring 55 mm. Intramedullary (IM) 9‐mm tibial nails were advanced to 6 mm from the ankle joint. Two transverse and one anterior–posterior (AP) locking screws were inserted. Both medial–lateral (ML) BSs were placed 10 mm from the topmost interlocking screw. A custom‐made jig assisted in placing the novel and traditional BSs. The time spent in placing each BS was recorded. All the samples were repaired with an IM nail and without BSs, with two traditional BSs, and with two novel BSs. An initial loading from −150 to +150 N was applied to specimens in the ML direction at 185 mm from the nail end, followed by cyclic loading of the same for 10,000 cycles with failure‐to‐test loading of 350 N in the ML direction. The maximum displacement was measured at 80 mm from the nail end and recorded under initial loading. The damage of two kinds of BSs to the nail was recorded.

Results

Compared with average 5.21 min of the time of placing a traditional BS, the time spent in positioning a novel BS on the fracture model was 2.53 min. In the distal bone–implant constructs (BICs), the addition of traditional BSs decreased the maximum displacement of the BICs by 26.2%. The addition of the novel BSs decreased the displacement by 28.9%. All constructs survived 10,000 cycles without hardware deformation. The failure rate of the control group was significantly greater than that of the traditional group; however, the novel group was similar to the traditional group. The damage of the traditional BS to the nail was greater than that of the novel one.

Conclusions

The novel and traditional BSs are comparably effective for increasing the primary mechanical stability of distal metaphyseal fractures after nailin. However, compared to the placement of a traditional BS, implanting a novel BS took more less time and caused less damage to the nail. Additionally, the most obvious advantage of the novel BS design and insertion technology was that the pressure and distance between it and the IM nail could be controlled by rotating the screw. These advantages of the novel BS will be beneficial for clinical application.

Clinical comparison of single-incision and dual-incision approaches for the treatment of distal tibial and fibular fractures: A randomized controlled trial

PURPOSE

The purpose of this study was to clinically compare the single-incision and dual-incision approaches for the treatment of distal tibial and fibular fractures.

METHODS

In total, 93 patients were enrolled, and the mean follow-up was 15 months (range 12-19 months). The patients treated for open reduction and internal fixation were randomly classified into two groups based on the approach used: 45 patients were treated using the single-incision approach (group 1) and 48 patients were treated using the dual-incision approach (group 2). In these two groups, operation time, discharge time, postoperative complications, and ankle function evaluations (Olerud-Molander Ankle Score) were compared between the two groups.

RESULTS

There were no significant differences in the mean operation time (98.2 ± 18.5 vs. 103.6 ± 19.3), discharge time (11.1 ± 3.9 vs. 12.5 ± 5.7), overall surgical complication rates (9/45 vs. 15/48), or ankle function between the two groups (p > 0.05). However, the rate of soft tissue-related complications, such as skin slough, infection, nonunion, and delayed union, was significantly lower in group 1 (5/45) than in group 2 (14/48) (p < 0.05).

CONCLUSION

The two incision approaches were found to have similar clinical outcomes. However, with regard to soft tissue conservation, the single-incision approach was superior to the dual-incision and maybe a reliable alternative.

Reduction techniques for intramedullary nailing of tibial shaft fractures: a comparative study

Objectives:

To assess the impact of various reduction techniques on postoperative alignment following intramedullary nail (IMN) fixation of tibial shaft fractures.

Design:

Retrospective comparative study.

Setting:

Level I trauma center.

Patients:

Four hundred twenty-eight adult patients who underwent IMN fixation of a tibial shaft fracture between 2008 and 2017.

Intervention:

IMN fixation with use of one or more of the following reduction techniques: manual reduction, traveling traction, percutaneous clamps, provisional plating, or blocking screws.

Main outcome measures:

Immediate postoperative coronal and sagittal plane alignment, measured as deviation from anatomic axis (DFAA); coronal and sagittal plane malalignment (defined as DFAA >5° in either plane).

Results:

Four hundred twenty-eight patients met inclusion criteria. Manual reduction (MR) alone was used in 11% of fractures, and adjunctive reduction aids were used for the remaining 89%. After controlling for age, BMI, and fracture location, the use of traveling traction (TT) with or without percutaneous clamping (PC) resulted in significantly improved coronal plane alignment compared to MR alone (TT: 3.4°, TT+PC: 3.2°, MR: 4.5°, P = .007 and P = .01, respectively). Using TT+PC resulted in the lowest rate of coronal plane malalignment (13% vs 39% with MR alone, P = .01), and using any adjunctive reduction technique resulted in decreased malalignment rates compared to MR (24% vs 39%, P = .02). No difference was observed in sagittal plane alignment between reduction techniques. Intraclass correlation coefficient (ICC) results indicated excellent intraobserver reliability on both planes (both ICC>0.85), good inter-observer reliability in the coronal plane (ICC = 0.7), and poor inter-observer reliability in the sagittal plane (ICC = 0.05).

Conclusions:

The use of adjunctive reduction techniques during IMN fixation of tibia fractures is associated with a lower incidence of coronal plane malalignment when compared to manual reduction alone.

Level of evidence:

Therapeutic Level III.

Staying Out of Trouble With Intramedullary Nailing of Distal Tibia Fractures

As the biologically friendly and biomechanically sound technique of intramedullary fixation has been increasingly applied to distal tibia diaphyseal fractures, challenges with the technique have emerged. Malalignment, most often valgus and recurvatum, is more common than with mid-diaphyseal patterns, given the lack of endosteal fit, and this can be challenging to prevent. Key technical steps can ensure success. These include recognition and initial fixation of intra-articular fracture planes, the use of percutaneous clamps, a slightly lateral terminal nail position, and the use of blocking wires or screws to prevent malalignment after nail passage. With thorough preoperative planning and early recognition of troublesome patterns, a variety of techniques can be applied to obtain and maintain a stable reduction throughout the procedure.

Combination of mini locking plate and nitinol arched shape-memory connector for purely lateral malleolus fractures: technique and clinical results

Background

Lateral malleolus fractures occur frequently. The common techniques for fixing purely lateral malleolus fractures are often challenging, owing to the extent of soft tissue damage and fracture non-union. Herein, we report a new treatment that entails minimally invasive insertion and continuous compression of the broken ends as a novel technique, and evaluate its clinical results.

Methods

This study enrolled 21 patients (13 males and 8 females; mean age 32.06±3.45 years, range 23–69 years) with purely lateral malleolus fractures. Each patient underwent open reduction treatment with a mini locking plate for internal fixation and compression of the fracture end with an Arched Shape-Memory Connector (ASC). The clinical assessments were made using the American Orthopedic Foot and Ankle Society (AOFAS) scores, which were recorded at the final follow-up visit.

Results

The patients were followed for an average of 14.7±1.2 months (range, 12–18 months). None of the patients showed surgical failure, and all of the purely lateral malleolus fractures healed in an average of 12.6±1.5 weeks (range, 10–16 weeks). The mean AOFAS score was 88.94 (range, 83–90).

Conclusions

The new treatment had beneficial outcomes for purely lateral malleolus fractures. Mini locking plates are minimally invasive for surgical intervention, and combined with continuous concentrated compression with an ASC to accelerate osseous healing, they aid in restoration of function and enable early rehabilitation with a low incidence of postoperative complications.

Ability of a Risk Prediction Tool to Stratify Quality and Cost for Older Patients With Tibial Shaft and Plateau Fractures

OBJECTIVES

To determine whether a validated trauma triage tool can identify the middle-aged and geriatric trauma patients with tibial shaft and plateau fractures who are at the risk for costly admissions and poorer hospital quality measures.

DESIGN

Prospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS/PARTICIPANTS

Sixty-four patients older than 55 years hospitalized with isolated tibial shaft or plateau fractures.

INTERVENTION

Patients with either isolated tibial plateau fractures or tibial shaft fractures over a 3-year period were prospectively enrolled in an orthopedic trauma registry. Demographic information, injury severity, and comorbidities were assessed and incorporated into the Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) score, a validated trauma triage score that calculates inpatient mortality risk upon admission. Patients were then grouped into tertiles based on their STTGMA score.

MAIN OUTCOME MEASURES

Length of stay, complications, discharge location, and direct variable costs.

RESULTS

Sixty-four patients met inclusion criteria. Thirty-three patients (51.6%) presented with tibial plateau fractures and 31 (48.4%) with tibial shaft fractures. The mean age was 66.7 ± 10.2 years. Mean length of stay was significantly different between risk groups with a mean of 6.8 ± 4 days (P < 0.001). Although 19 (90.5%) of the minimal risk patients were discharged home, only 7 (33.3%) and 5 (22.7%) of moderate- and high-risk patients were discharged home, respectively (P < 0.001). Higher-risk patients experienced a significantly greater number of complications during hospitalization but had no differences in the need for intensive care unit-level care (P = 0.027 and P = 0.344, respectively). The total cost difference between the lowest- and highest-risk group was nearly 50% ($14,070 ± 8056 vs. $25,147 ± 14,471; mean difference, $11,077; P = 0.022).

CONCLUSION

Application of the STTGMA triage tool allows for the prediction of key hospital quality measures and cost of hospitalization that can improve clinical decision-making.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tibial shaft fractures treated with intramedullary nailing and reduction device assistance

PURPOSE

This study aimed to assess the outcomes of a newly invented reduction device on assisting reduction of intramedullary nailing (IMN) in the treatment of tibial shaft fractures.

METHODS

From January 2015 to December 2018, data of patients with tibial shaft fractures treated with IMN were reviewed. In total, 42 patients underwent treatment with the new reduction device (group A) and 56 underwent treatment using a traditional reduction technique (group B). Data related to the closed reduction rate, surgical time, blood loss, number of fluoroscopies, number of surgeons, and number of complications were also reviewed. Fracture healing was assessed using radiographs at each follow-up, and the functional outcome (AOFAS score) was evaluated at the final follow-up.

RESULTS

The two treatment groups were evenly matched with respect to age, sex, fracture grade, and time to surgery. The average surgical time, blood loss, number of fluoroscopies, and number of surgeons in group A were all lesser than those in group B (P < 0.05). The closed reduction rate in group A was higher than those in group B (P < 0.05). The fracture healing time, AOFAS score, and complication rate were not significantly different (P > 0.05) between the two groups.

CONCLUSION

The new reduction device could effectively achieve and maintain the reduction of tibia shaft fractures in a minimally invasive fashion.

Total Knee Arthroplasty After Intramedullary Tibial Nail: A Matched Cohort Study

BACKGROUND

As the use of intramedullary nails (IMNs) has become more common, there are an increasing number of patients requiring total knee arthroplasty (TKA) who have an indwelling tibial IMN. The purpose of this study is to compare implant survivorship, clinical outcomes, and complications in patients undergoing primary TKA with a history of tibial IMN to those without.

METHODS

We retrospectively identified 24 TKAs performed between 2000 and 2017 after ipsilateral tibial IMN. Patients were matched 1:2 to patients undergoing primary TKA without history of tibial IMN based upon age, gender, body mass index, and year of surgery. Mean follow-up was 7 years.

RESULTS

The 10-year survivorship free of any revision was 100% for the tibial IMN cohort, and 96% for the control cohort, while the 10-year survivorship free of any reoperation was 91% and 89%, respectively (P = .72). Patients with a history of tibial IMN had similar Knee Society Scores to matched controls at 2 years (P = .77) and 5 years (P = .09). Acquired idiopathic stiffness trended toward being more common (17% vs 6%, P = .21) and operative time trended toward being longer (135 vs 118 min, P = .07) when the tibial IMN was removed, but there was no overall difference in complication rate between cohorts.

CONCLUSIONS

To our knowledge, this is the first report of primary TKA in patients with a history of ipsilateral tibial IMN. Compared to a matched cohort of patients without tibial IMN, these patients have similar outcomes in regards to implant survivorship, clinical outcomes, and risk of complications.

LEVEL OF EVIDENCE

Therapeutic Level III.

Management of Tibial Shaft Fractures Distal to TKA Prosthesis by Intramedullary Nail: A Report of Three Cases

INTRODUCTION

Diaphyseal tibial fractures distal to a well-fixed tibial component although rare present a significant challenge and optimal treatment remains controversial. Displaced periprosthetic tibial shaft fractures are ideally treated with open reduction internal fixation with plate osteosynthesis. However, this treatment method is associated with weight-bearing restrictions, which can be difficult for elderly patients with multiple comorbidities and balance impairment. We present our experience of internal fixation with an intramedullary nail that uses an inferior entry point, standard intramedullary tibial nail, and conventional instrumentation.

MATERIALS AND METHODS

Between 2017 and 2018, three patients with acute tibial shaft fractures distal to a TKA (Felix Type 3A) were treated with an intramedullary nail. Preoperative planning involved assessing proximal tibia to ensure adequate room for implant and instrumentation. The average patient age was 66.3 years (range 59-72 years) and all patients were males. All the patients sustained fractures of distal tibial and fibula diaphysis, after a road traffic accident. There were no complications intraoperatively, and all procedures were completed uneventfully. One patient underwent additional fixation of the fibula.

RESULTS

All patients achieved a radiological fracture union after an average of 20.6 weeks. There were no fixation failures, or nonunions postoperatively. There were no new symptoms relative to the TKA that could be attributed to the tibial nailing procedure.

CONCLUSION

We recommend that this technique can be used primarily for this fracture pattern distal to a TKA, provided there is adequate space to accommodate the nail and instrumentation proximally anterior to the tibial tray.

Comparison of 3 Treatment Methods for Distal Tibial Fractures: A Network Meta-Analysis

Background

The choice of optimal internal fixation device for distal tibial fractures remains controversial. The purpose of our study was to evaluate the effectiveness and safety of open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and intramedullary nailing of distal tibial fractures in adults using network meta-analysis of data from clinical trials.

Material/Methods

The studies were abstracted from MEDLINE, EMBASE, CNKI, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials meeting inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 13.0 (Stata Corporation, College Station, Texas, USA).

Results

Eleven randomized controlled trials were included. The total number of participants was 710 and the studies were published between 2005 and 2017. There were no significant differences in rates of delayed union, nonunion, or malunion among the various treatments (all p>0.05). The intramedullary nailing group had a lower incidence of wound complications than did the open reduction and internal fixation group and minimally invasive percutaneous osteosynthesis technique group. The SUCRA probabilities were 28.6% for ORIF, 98.4% for IMN, and 22.9% for MIPPO.

Conclusions

Given the superior results for intramedullary nailing in terms of wound complications, we recommend this procedure for treatment of distal tibial fractures. More RCTs focused on distal tibial fractures are needed to support the current evidence.

Comparison of plate and intramedullary nail fixation of extra-articular tibial fractures: A retrospective study exploring hidden blood loss

PURPOSE

To explore the hidden blood loss (HBL) in treatment of extra-articular tibial fractures with plate and intramedullary nail fixation.

METHODS

We conducted a retrospective study including 209 consecutive patients treated by plate (Group LCP) or intramedullary nail fixation (Group IMN) for extra-articular tibial fractures between January 2015 to December 2017. Demographics, intraoperative data, perioperative laboratory values, transfusion rate, and early complications were collected and analyzed.

RESULTS

Of 209 patients, 96 patients fixed with IMN and 113 fixed with LCP. The average HBL was 272.71 ± 57.88 ml in Group LCP and 507.66 ± 109.81 ml in Group IMN, and there was statistical difference in the HBL between two groups (p < 0.001). The Hb and Hct loss, surgical duration, and postoperative number of anemic patients in Group IMN were significantly higher than in Group LCP (p < 0.001), and IMN fixation has a significantly higher rate of transfusion (p = 0.027), whereas patients in group IMN has significantly less VBL (p < 0.001), shorter postoperative hospital stay (p < 0.001), and less superficial infection (p = 0.014).

CONCLUSIONS

There was a significant amount of hidden blood loss after reamed intramedullary nail fixation for extra-articular tibial fractures, which was much higher than expected. In view of the morbidity of acute anaemia and transfusion, we suggest that for patients who suffer from extra-articular tibial fractures with multiple injuries, or those with low haemoglobin preoperatively, plates might be more suitable than nail fixation.

Does the Use of Blocking Screws Improve Radiological Outcomes Following Intramedullary Nailing of Distal Tibia Fractures?

Aim

The aim of this study is to assess whether the addition of blocking screws during intramedullary nailing of a distal tibia fracture improved the radiological outcome and prevented a loss of fracture alignment. As a secondary outcome, the time to radiographic union was compared to see if a more rigid bone-implant construct had an effect on healing.

Methods

We searched computerized records at a UK level 1 major trauma center. The joint alignment was measured on the immediate postoperative radiograph and compared to the most recent radiograph. We used a difference of 2° to indicate a progressive deformity.

Results

Thirty patients were included. Twenty patients had no blocking screw and 10 patients had a blocking screw. Six patients had a difference in their coronal plane alignment of 2° or more (3/6 had no blocking screw). The results were analyzed and found to be not statistically significant (p = 0.82). The addition of a blocking screw has also been shown not to have an effect on the time to radiological union (RUST score greater or equal to 10).

Conclusion

We use a 2.5-mm blocking wire to aid in fracture reduction prior to reaming or nail insertion and then remove the wire when the nail has been adequately locked. We no longer routinely replace the wire with a blocking screw and this could lead to a decrease in procedure time, cost, and radiation exposure.

How to cite this article

Fawdington RA, Lotfi N, Beaven A, et al. Does the Use of Blocking Screws Improve Radiological Outcomes Following Intramedullary Nailing of Distal Tibia Fractures? Strategies Trauma Limb Reconstr 2019;14(1):11–14.

Minimally invasive percutaneous plate osteosynthesis versus intramedullary nail fixation for closed distal tibial fractures: a meta-analysis of the clinical outcomes

Introduction: Minimally invasive percutaneous plate osteosynthesis (MIPPO) has emerged as a viable alternative for the treatment of distal tibial fractures. However, the clinical outcomes of this procedure compared to intramedullary (IM) nail fixation have yet to be established. The present meta-analysis aims to compare the clinical outcomes following MIPPO and IM nail fixation for closed distal tibial fractures.

Methods: MEDLINE and EMBASE databases were searched from date of inception to 10th April 2017. Randomized controlled trials (RCTs) comparing MIPPO with IM nail fixation for closed and Gustilo Grade I distal tibial fractures were included. Outcomes assessed included time to union, complications and functional outcomes. Quality and risk of bias of the RCTs were assessed using the Cochrane Collaboration Tool.

Results: Five RCTs comprising 497 patients were included. MIPPO was associated with a longer time to union (MD: 1.08, 95% CI: 0.26, 1.90, p = 0.010, I²= 84%) and increased risk of wound complications (RR: 1.58, 95% CI: 1.01, 2.46, p = 0.04, I² = 0%). Both MIPPO and IM nail fixation had comparable risks of malunion, delayed union, non-union and deep infections, with similar functional outcomes.

Discussion: Compared to IM nail fixation, a MIPPO fixation technique for distal tibial fractures is associated with a longer time to fracture union and an increased risk of wound complications. Neither technique demonstrates a clear advantage with regard to risk of malunion/non-union, or functional outcome. Assuming equivalent surgical expertise with both techniques, the results suggest that IM nail fixation is the treatment modality of choice for these challenging fractures.

The risk of violating the posterior malleolar fracture when nailing the ipsilateral concomitant spiral distal tibial fracture

Background

For a distal tibial spiral fracture combined with a non-displaced posterior malleolar fragment (PMF), we proposed a hypothesis that the treating surgeon could assess the size of the PMF to determine the need for stabilizing that structure first before rodding the tibia.

Materials and methods

Fifty 3-D models (22 females) of combined distal tibial and posterior malleolar fractures from one trauma center were reconstructed. In each case, a virtual tibial intramedullary nail (vIM nail) with three distal anteroposterior (AP) locking screws (S₁₃, S₁₅ and S₃₇, the number indicating the distance from the screw to the nail tip) were inserted into the center of the tibial canal and ended on top of the distal tibial physeal scar. Contact between the screws and the PMF was defined as causing PMF displacement. The relationship between PMF secondary displacement and traumatic anatomic factors (the fragment area and height of the PMF) was explored. Then, the parameters were justified by analyzing intraoperative radiographs of 35 cases treated by nail with single locking screw (S₁₅) design.

Results

In the analog experiment, multiple logistic regression analysis revealed that the height of the PMF could confidently predict the risk of fragment displacement (S₁₃: odds ratio [OR] 1.18, 95% confidence interval [CI] 1.06–1.32; S₁₅: OR 1.15, 95% CI 1.05–1.27). Regarding the height of the PMF, the receiver operating characteristic established a cut-off value of 31.2 mm for preliminary fixation of the fragment with 88.89% sensitivity and 88.89% specificity. In the operation group the nail stopped on the top of distal tibial physeal scar, no PMF secondary displacement occurred when the PMF height was less than 31.2 mm. However, the incidence of secondary displacement was 93.33% when the height of the PMF exceeded 31.2 mm.

Conclusion

When the distal tibial physeal scare was set as the limit of nail insertion depth, the height of the PMF could be used as a reliable reference predicting the risk of PMF secondary displacement caused by distal anteroposterior locking screw.

Comparing intramedullary nailing and plate fixation for treating distal tibail fractures: A meta-analysis of randomized controlled trials

BACKGROUND

Intramedullary nailing (IMN) and plate have been reported as two effective devices for treating distal extra-articular fractures. However, reports of complications after fractures with use of different tibial fixation techniques in literature are controversial. Thus, we performed a meta-analysis of randomized controlled trials (RCTs) to compare IMN with plate for evaluating the safety and efficacy.

METHODS

The studies were searched from PubMed, Embase, Web of science and the Cochrane Central Register of Controlled Trials by two reviewers up to August 2017. The quality of RCTs was assessed by Cochrane Handbook. Data were extracted from studies and analyzed by Review Manager 5.3. 95% confidence interval (CI) and risk ratio (RR) were calculated for dichotomous data.

RESULTS

Eight RCTs with 482 patients were included in the meta-analysis. We found no statistically significant differences between IMN and plate on union time (SMD = -0.20, 95%CI -0.58 to 0.18, P = 0.3), delayed or nonunion (RR = 1.19, 95%CI 0.66 to 2.14, P = 0.56) and malunion (RR = 1.63, 95%CI 1.01 to 2.65, P = 0.05). IMN group had shorter operative time (P < 0.0001) and radiation time (P < 0.0001), lower incidence of wound complications (P = 0.0003) and higher rate of knee pain (P < 0.0001) than the plate group.

CONCLUSION

The meta-analysis showed that intramedullary nailing reduced the time of surgery and radiation and the risk of wound complications compared with plate fixation. Furthermore, union time and union complications were common following both treatments. Overall, intramedullary nailing is found to be taken priority for distal tibial metaphyseal fractures. More RCTs are required to support current evidence.

Soft tissue complications in distal tibial fractures managed with medial locking plates: A myth or reality?

BACKGROUND

Distal tibial fractures are common injuries that are prone to complications and require careful management. The use of medial periarticular locking plates is an established modality in the treatment if these fractures. These plates are inserted using the minimally invasive plate osteosynthesis (MIPO) or open technique. Our study looks at the soft tissue complications associated with the use of medial locking plates in the management of these fractures.

METHODS

This was a retrospective study carried out at a tertiary care university hospital in an urban setting. Forty four patients with distal tibia fractures treated with periarticular locking plates during a three year period were included in the study. Both closed and open fractures were included while those with an established non-union were excluded. Patient data related to inpatient stay, outpatient visits as well as readmissions was extracted from hospital records and analysed. Spanning external fixation was done if necessary and definitive fixation was done using medial locking plates with either MIPO technique or open reduction and internal fixation (ORIF) with biological technique. The sub cohort of patients with soft tissue complications was compared to the parent group.

RESULTS

The study group included 44 patients (28M:16F) with 45 fractures with a median age of 42.6 years (range 18-65 years) followed up for a mean of 9.2 months (range 5-20 months). Domestic falls were the cause of injury in 61.4% (n = 27) of the fractures. The average time to union was 26.2 weeks (range 12-66 weeks). Out of these 45 fractures, soft tissue complications were seen in 22.2% of cases (n = 10) with road side accidents seen in 60% (n = 6) of cases. In four patients, there was difficulty in achieving primary wound closure and in five other cases wound dehiscence with exposure of implant was seen within 12 to 30 days of surgery. One patient required secondary suturing after readjustment for malreduction. No statistically significant difference was found in the parent cohort and the sub cohort with soft tissue complications with respect to the use of spanning external fixator, MIPO/ORIF technique or fibular fixation.

CONCLUSION

The incidence of soft tissue complications with the use of medial locking plates in distal tibial fractures may be more than what is currently reported in literature and further studies are required to shed more light on this subject.

Minimally invasive posteromedial percutaneous plate osteosynthesis for diaphyseal tibial fractures: technique description

PURPOSE

The aim of this study was to evaluate the feasibility of performing minimally-invasive plate osteosynthesis (MIPO) in tibial fractures using two posteromedial incisions, and to measure the distance between the plate and neurovascular structures.

MATERIALS AND METHODS

We performed nine dissections of specimens that were submitted to tibial MIPO with two posteromedial incisions. One locking compression plate (LCP) of 14 to 16 holes was inserted into the submuscular tunnel in a retrograde manner. Incisions were linked to evaluate the distance between neurovascular structures and the plate.

RESULTS

During the proximal incision, a blunt dissection between semitendinosus and medial gastrocnemius tendons, as well as their lateral shift, helped to protect the main local neurovascular structures. In its distal portion, the submuscular plate tunnel insertion and its direction to the proximal incision prevented direct contact and possible damage to neurovascular structures. Moreover, we obtained successful results from a patient submitted to this procedure.

CONCLUSION

Posteromedial MIPO represents a safe and attractive alternative for tibial fractures, particularly if there are damaged soft tissues in the anterior and medial side, or when access to intramedullary osteosynthesis is blocked.