Abstract
BackgroundFor 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 methodsFifty 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.ResultsIn 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.ConclusionWhen 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.
Highlights
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
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)
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
Summary
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. The suggestion of indiscriminate PMF fixation with cannulated screws before nailing was made without sufficient supporting evidence and is not an effective solution [6]. This protocol might irritate the adjacent tendon (especially the hallux flexor longus from the posteroanterior screw) and ligaments, cause percutaneous nerve entrapment [7], exaggerate excessive patient radiation exposure and incur extra financial cost. As the treatment benefit should be balanced against the potential complications and costs, we believe it is wise to tailor the operation protocol for every case
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