Clinical Faceoff: Suprapatellar Tibial Nailing for Tibia Fractures

Controlling the angle between the distal locking screw and tibiotalar joint tangent helps to reduce the occurrence of misalignment of distal tibial fractures treated with intramedullary nail fixation

BACKGROUND

Studies have shown that on the coronal plane, whether the direction of the distal locking screw is parallel to the tangent line of the tibiotalar joint can be used to determine whether there is varus or valgus deformity after the treatment of distal tibial fractures with intramedullary nail (IMN) fixation. However, there has been no statistical analysis of the included angle on the coronal plane, and there have been no reports on whether there is a relationship between the direction of the distal locking screw on the sagittal plane or the included angle of the tangent line of the tibiotalar joint and the postoperative alignment of distal tibial fractures treated with IMN fixation.

OBJECTIVE

Our aim was to evaluate the relationship between the angles formed by the distal locking screw and the tibiotalar joint tangent (ADTTs) on the sagittal and coronal planes and postoperative alignment in the treatment of distal tibial fractures with IMN fixation.

METHODS

We performed a retrospective analysis of 100 patients with distal tibial fractures treated with IMN fixation using the suprapatellar approach. On the coronal and sagittal planes, the ADTTs were arranged from small to large and divided into 4 groups, namely, groups A, B, C and D. One-way ANOVA was used to compare the lateral distal tibial angle (LDTA) and anterior distal tibial angle (ADTA) among all groups, and the chi-square test was used to compare the incidence of postoperative tibial misalignment among all groups. Univariate analysis was performed using chi-square tests to identify factors that might be associated with dislocation, including fibular open reduction and internal fixation (ORIF), limited open reduction, ADTT, IMN diameter, injury mechanism, open vs. closed fracture, comminution, and fibular fracture level. Then, the statistically significant variables in the univariate analysis were included in a multivariate logistic regression equation to evaluate the independent factors related to misalignment.

RESULTS

On the coronal plane, the ADTTs of groups A, B, C and D were < 0°, 0°-1.3°, 1.3°-2.7° and > 2.7°, respectively. The mean LDTAs of groups B and C (0°-1.3° and 1.3°-2.7°), group A (< 0°) and group D (> 2.7°) were 89.5 ± 1.6°, 92.0 ± 3.2° and 85.8 ± 3.5°, respectively (P < 0.01). Deformity greater than 5° were more likely in groups A and D than groups B and C [14 of 50 (28%) vs. 1 of 50 (2%), P < 0.001]. On the sagittal plane, the ADTTs of groups A, B, C and D were < 8.9°, 8.9°-10.4°, 10.4°-11.7° and > 11.8°, respectively. The average ADTAs of groups B and C (8.9°-10.4° and 10.4°-11.7°), group A (< 8.9°) and group D (> 11.8°) were 80.4 ± 1.3°, 83.1 ± 3.7° and 77.9 ± 2.5°, respectively (P < 0.01). Deformity greater than 5° was more likely in groups A and D than groups B and C [13 of 50 (26%) vs. 0 of 50 (0%), P < 0.001]. An ADTT of 0°-2.7° on the coronal plane and 8.9°-11.7° on the sagittal plane (OR: 0.08, P = 0.02) and limited open reduction (OR: 0.21, P < 0.01) were independent factors that reduced the likelihood of misalignment.

CONCLUSION

The alignment of distal tibial fractures after surgery is sensitive to the ADTT and use of limited open reduction. Controlling the ADTT between 0° and 2.7° on the coronal plane and between 8.9° and 11.7° on the sagittal plane is helpful to reduce the occurrence of misalignment after the treatment of distal tibial fractures by IMN fixation.

Removing a suprapatellar intramedullary nail via a suprapatellar approach: a retrospective cohort study

BACKGROUND

Over the last 20 years, suprapatellar (SP) intramedullary nailing has gained considerable attention for treating tibia fractures and is believed to improve fracture alignments, decrease anterior knee pain, and facilitate intraoperative fluoroscopy. However, it is associated with various concerns, including the need to make another infrapatellar (IP) incision to remove the nail.

AIMS

This study was aimed at developing a new technique for the removal of SP tibial nails through an SP approach using a cannulated extraction system. The efficiency of the novel SP approach was compared to that of the traditional IP approach for the removal of SP tibial nails.

PATIENTS AND METHODS

This was a retrospective cohort study from a prospectively collected clinical registry. The data for 69 consecutive patients who received surgery to remove a previous SP intramedullary nail using an SP approach (n = 30, SP cohort) or an IP approach (n = 39, IP cohort) were analyzed. Intra-operative evaluations included intraoperative blood loss, operation time, and changes in the surgical procedures. At six months follow-up, post-operative Lysholm knee score, visual analog scale (VAS) score, and the active range of motion (ROM) of the affected knee and complications were assessed.

RESULTS

Patients in the SP cohort exhibited an increased post-operative Lysholm knee score (β, 2.6; 95% confidence interval [CI], 0.6 to 4.6; P = 0.012), decreased post-operative VAS score (β, - 0.7; 95% CI, - 1.1 to - 0.2; P = 0.004), and increased operation time (β, 9.8 minutes; 95% CI, 5.7 to 14.0 minutes; P < 0.001) compared with those treated with the IP approach after adjustment for baseline characteristics. There were no statistically significant differences in blood loss, post-operative ROM, or complications between the two cohorts.

CONCLUSIONS

Compared with the IP technique, the SP approach for the removal of an SP tibial nail was independently associated with an increased post-operative Lysholm knee score and decreased VAS score, although the surgery was longer in duration. The novel technique offers a reliable and minimally invasive option for the removal of an SP tibial nail.

An Approach to Intraoperatively Identify the Coronal Plane Deformities of the Distal Tibia When Treating Tibial Fractures with Intramedullary Nail Fixation: a Retrospective Study

Objective

To develop a new approach to intraoperatively identify the presence of coronal plane deformities (both valgus and varus) when treating tibial fractures with closed reduction and intramedullary nail fixation.

Methods

A retrospective analysis was conducted by enrolling 33 consecutive patients with tibial fractures who received closed reduction and intramedullary nail fixation from January 2018 to January 2019 at our trauma center. Out of the 33 patients, 23 were males and 10 were females and the average age was 41 years (ranging 22 to 69 years of age). Standard anteroposterior and lateral preoperative radiographs were routinely performed. After intraoperatively inserting the tibial intramedullary nail through the standard entry point, the parallel relationship between the distal horizontal interlocking screw and the tibiotalar joint surface on the anteroposterior fluoroscopy was used to determine the occurrence of valgus or varus deformities of the distal tibial fragment. Radiographic and clinical outcomes were analyzed using the average interval from injury to surgery, the lateral distal tibial angle (LDTA) of the unaffected and affected sides, complications and the Olerud–Molander ankle score.

Results

All 33 patients were postoperatively followed for 13 to 25 months (mean 18.7 months). The fractures achieved bone union at an average of 4.3 months (ranging from 3 to 6 months). The total complication rate was 60.6% (20 cases), including four cases that showed deep vein thrombosis, one case showing an infection and delayed union and 15 cases showing slight to moderate anterior knee pain. The postoperative LDTA of the unaffected side measured 87.3° to 89.6 ° (average 88.7° ± 0.8°), and the LDTA of the affected side was 87.5° to 90.4° (average 88.9° ± 1.1°). There was no significant difference between the unaffected and affected sides (t = −1.865, P = 0.068). The intraoperative measurement indicated six cases of valgus angulation and three cases of varus angulation deformities, and all deformities were corrected during surgery. According to the Olerud–Molander ankle score, clinical outcomes demonstrated 22 excellent cases, eight good cases, two fair cases, and one poor case 12 months after surgery.

Conclusion

The parallel relationship between the distal horizontal interlocking screw and tibiotalar joint surface on intraoperative anteroposterior films were able to determine the onset of valgus or varus angulations of the distal tibial fragment in the fracture zone after the tibial intramedullary nail was inserted through the standard entry point.

Semi-extended intramedullary nailing of the tibia using an infrapatellar approach: a retrospective cohort study

PURPOSE

The semi-extended tibial intramedullary nailing method would enable easier and improved reductions for tibial fractures as well as facilitate fluoroscopic imaging; however, its in-articular nature remains controversial. The aim of this study was to compare the clinical and functional outcomes of the semi-extended infrapatellar (SEIP) approach and hyper-flexed infrapatellar (HFIP) approach for intramedullary nailing to treat tibial shaft fractures.

METHODS

This study involved the retrospective analysis of the medical records of patients with tibial shaft fractures that were fixed through either the SEIP approach or the HFIP approach of intramedullary nailing and who were admitted to a level 1 trauma centre. The minimum patient follow-up period was 12 months and the clinical and functional outcomes were estimated at the 12-month visit.

RESULTS

Of the 80 patients whose medical records were analyzed, 40 (50%) underwent SEIP nailing and the remaining 40 (50%) underwent the traditional HFIP nailing. Compared with the HFIP group, patients in the SEIP group had a higher Lysholm knee score (median, 92 [interquartile range, 88-95] vs median, 88 [interquartile range, 81-92]; p = .01), a shorter intra-operative fluoroscopy time (median, 93 [interquartile range, 78-105] s, vs median, 136 [interquartile range, 110-157] s; p < .001), and operation time (mean, 88.1 [SD, 17.8] min vs mean, 98.7 [SD, 19.3] min; p = .01). The VAS score was significantly lower in the SEIP group (median, 0; interquartile range, 0-0) than in the HFIP group (median, 0; interquartile range, 0-2) (p = .03). There were two cases (5%) in the SEIP group and 10 cases (25%) in the HFIP group of moderate AKP (p = .03). Meanwhile, there was no significant difference in malalignment, nonunion, delayed union, infection, and other complications, as well as SF-36 physical and mental scores.

CONCLUSION

We found that the SEIP approach to tibia intramedullary nailing was superior to the HFIP approach based on the intra-operative and post-operative outcomes. Thus, this novel technique provides an infrapatellar option for semi-extended tibial nailing.