Intramedullary Nailing Of Tibial Fractures Research Articles

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

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. 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 1year. 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. The mean patient age was 47.7years (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 ≥ 7days (OR = 1.3, 95% CI = 1.3-8.1) and age over 50years (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). 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.

Imaging risk factors for predicting postoperative complications of intramedullary nailing for tibial fracture.

The objective of this study was to analyze the ratio of fracture site diameter to tibial isthmus diameter (TFI ratio) as a predictor of postoperative complications, including malunion and delayed union, after tibial intramedullary nailing for middle and lower tibial fractures. Data were collected from all adult patients older than 20 years of age who underwent tibial intramedullary nailing for middle and lower tibial fractures between January 2015 and January 2023 and were followed up for at least 1 year. Diabetes history, smoking history, fracture type, injury mechanism, surgical method, surgical approach, diameter of the medullary cavity at the fracture site, and diameter of the tibial isthmus were recorded. Logistic regression analysis was used to determine the variables affecting the occurrence of complications. The TFI ratio was used to calculate the sensitivity and specificity of the parameters, and ROC curves were generated to establish TFI ratio thresholds for predicting complications. A total of 123 patients with middle and lower tibial fractures were treated with intramedullary nails. The mean age of the patients was 43.72 years (range, 21-81 years); 89 were males, and 34 were females. Univariate logistic regression analysis showed that fracture type, open reduction surgery, superior patellar approach, and TFI ratio were significantly correlated with postoperative complications after intramedullary nailing of a tibial fracture. Multivariate logistic regression analysis showed that the TFI ratio was an independent risk factor for complications (P = 0.001*). By using the TFI ratio as a predictor of complications, an ROC curve was generated to establish a threshold. The ROC curve showed that a TFI ratio ≥ 1.31 had a sensitivity of 0.89, a specificity of 0.71, and an area under the ROC curve of 0.82 for predicting complications. The results of this study suggest that a wider intramedullary diameter and a shorter fixed length at the fracture site are associated with a higher incidence of complications after tibial intramedullary nailing. The TFI ratio may be used as a reliable parameter for predicting complications after such surgery. In patients with a high TFI ratio (≥ 1.31), additional reduction and fixation techniques may be needed to obtain and maintain fracture reduction.

Medullary cavity application of tranexamic acid to reduce blood loss in tibial intramedullary nailing procedures—a randomized controlled trial

PurposeStudies have shown an average postoperative hidden blood loss (HBL) of 473.29 ml and an average Hb loss of 16.71 g/l after intramedullary nailing. Reducing HBL has become a primary consideration for orthopaedic surgeons.MethodsPatients with only tibial stem fractures who visited the study clinic between December 2019 and February 2022 were randomized into two groups using a computer-generated form. Two grams of tranexamic acid (TXA) (20 ml) or 20 ml of saline was injected into the medullary cavity before implantation of the intramedullary nail. On the morning of the surgery, as well as on days one, three and five after surgery, routine blood tests and analyses of CRP and interleukin-6 were completed. The primary outcomes were total blood loss (TBL), HBL, and blood transfusion, in which the TBL and HBL were calculated according to the Gross equation and the Nadler equation. Three months after surgery, the incidence of wound complications and thrombotic events, including deep vein thrombosis and pulmonary embolism, was recorded.ResultsNinety-seven patients (47 in the TXA group and 50 in the NS group) were analyzed; the TBL (252.10 ± 10.05 ml) and HBL (202.67 ± 11.86 ml) in the TXA group were significantly lower than the TBL (417.03 ± 14.60 ml) and HBL (373.85 ± 23.70 ml) in the NS group (p < 0.05). At the three month postoperative follow-up, two patients (4.25%) in the TXA group and three patients (6.00%) in the NS group developed deep vein thrombosis, with no significant difference in the incidence of thrombotic complications (p = 0.944). No postoperative deaths or wound complications occurred in either group.ConclusionsThe combination of intravenous and topical TXA reduces blood loss after intramedullary nailing of tibial fractures without increasing the incidence of thrombotic events.

MINIMALLY INVASIVE OSTEOSYNTHESIS WITH PLATE OR NAIL FOR META-DIAPHYSEAL TIBIAL FRACTURES - WHAT IS BETTER?

The aim of this article is to review the surgical techniques for minimally invasive osteosynthesis and associated complications with application of locking compression plates, which have undeniable biomechanical and biological advantages in the treatment of multifragmentary meta-diaphyseal tibial fractures. Unstable proximal tibial fractures include a vast majority of fracture patterns affecting the lower extremities. Most of the fracture types are as a result of high-energy trauma from car accidents, high-altitude injury or motor vehicle incident. Usually, those fractures present with severe soft tissue injury with varying degrees of intra-articular fracture involvement. Intramedullary nailing of tibial fractures as a proven method of biologic fixation and represents one of the most widely used methods for the treatment of unstable fractures involving the proximal meta-diaphyseal area of the tibia, allowing sufficient fracture stability during the early limb movement and weight bearing on the leg. Nevertheless, the complications and technical difficulties in its application raise the question for the choice of an appropriate implant in the treatment of these fracture models in terms of their morphology. Minimally invasive percutaneous plate osteosynthesis with indirect reduction and biologic fixation has the advantage of spearing the local blood flow, even in severely comminuted tibial fracture patterns. The use of pre-contoured locking compression plates for proximal tibia allows stable fixation with good and excellent final clinical results.

The role of acupuncture in pain and swelling control for postoperative tibial fracture treatment.

BackgroundCurrently, intramedullary nailing for tibial fractures has very good postoperative treatment results. Combining the advantages of traditional medicine and modern medicine is a comprehensive treatment method that brings the best benefits to the patient.MethodsThe study method was a controlled clinical trial. The study included 60 patients with a definitive diagnosis of tibial fracture who underwent intramedullary nailing surgery. These patients were divided into 2 groups: with and without electroacupuncture treatment.ResultsElectro-acupuncture had a significant analgesic effect in 24–48 h after surgery: After 24 h or electro-acupuncture, the pain difference in the study group and the control groups was 3.03 ± 1.25 and 2.46 ± 1.33, respectively (p < 0.05). The VAS score difference between day 1 and day 2 in the study group and the control group was 0.61 ± 0.71 and 0.59 ± 0.67, respectively (p < 0.05). At 48 h postoperatively, the circumference of the calf on the fractured side in the study group and the control group was 36.1 ± 2.1 and 37.3 ± 2.2 cm, respectively (p < 0.05). At 72 h postoperatively, the circumference of the calf in the study group and the control group was 35.9 ± 2.6 and 37.6 ± 2.8 cm, respectively (p < 0.05). The effect of electro-acupuncture on bone healing did not differ between the study group and the control group (p > 0.05). During 7 days of using the treatment regimen, there were 3.3 % of patients with dizziness, 3.3 % of patients with vomiting/nausea, 3.3 % of patients with bleeding at the injection site. There was no difference in blood pressure, pulse rate, hematological indexes and biochemical indexes of patients before and after using the treatment regimen.ConclusionElectro-acupuncture has a significant analgesic effect 24 h–48 h after surgery. The effect of electroacupuncture on bone healing was not different between the two groups. Electroacupuncture is a safe, effective method with few side effects.

What Would be the Difference Between Operative Treatment of Patients with Tibia Fractures out of Working Hours; Intramedullary Nailing for Tibial Shaft Fractures.

Performing orthopedic surgery in and out of working hours may affect the success of the surgery. Timing of surgery in tibial shaft fractures is controversial. In this study, the effect of the timing of surgery on the success and complications of intramedullary nailing of tibial fractures is examined. Archieves of patients with tibial shaft fractures treated with reamed intramedullary nails between 2010 and 2016 were retrospectively analyzed. Fifty-seven patients were included in the study. Patients were categorized by the time of the surgery. Day time (Group I) is between 7:00 am and 5:00 pm and after hour (Group II) is between 5:00 pm and 07:00 am. Group I (n: 40) and Group II (n: 17) were evaluated. Technical errors, surgery time, and length of hospital stay statistical analysis was performed between the two groups in terms of technical errors, complication rates, length of hospital stay, and duration of surgery. The mean duration of operation (p=0.419), number of distal screws (p=0.847), time to union (p=0.454), experience of the surgeon (p=0.192), and technical error rate (p=0.654) did not differ significantly between two groups. Length of hospital stay and time to surgery from emergency were significantly higher in day time group. Technical errors and surgery time of intramedullary nailing of tibial shaft fractures are not higher at after hour before midnight than day time. Non-urgent tibial shaft fractures might be treated with intramedullary nailing at after hours before midnight for efficient use of hospitals.

Patella baja after intramedullary nailing of tibial fractures, using an infrapatellar/transtendinous approach, predicts worse patient reported outcome

PurposeAfter intramedullary nailing of tibial shaft fractures using an infrapatellar/transtendinous approach, several patients suffer anterior knee pain. We suspect that the approach is associated with soft tissue scars and the development of a postoperative patella baja. The goal of the study is to investigate whether the development of patella baja is associated with worse subjective outcomes.MethodsWe retrospectively analyzed all patients in our orthopedic trauma department between 2011 and 2020 who underwent tibial fracture fixation via intramedullary nailing via an infrapatellar/transtendinous approach. Pre- and postoperative lateral knee x-rays were evaluated by measurement of the Insall-Salvati Index, and nail tip position. All patients were asked to answer the self-assessment Kujala questionnaire and Lysholm questionnaire.ResultsWe included 78 patients (age: 44 ± 18 years) with a minimum follow-up of 12 months. Mean follow up was 59 ± 25 months. We included 50 male and 28 female patients. Patella baja detected by Insall-Salvati Index could be observed in 8 (10.3%) patients. Patients with patella baja showed significant worse function measured by the Kujala score 54 ± 18 vs. 80 ± 14 (p < 0.01). Likewise, Lysholm score did show significant differences between both groups (60 ± 24 vs. 86 ± 11; p < 0.01). Nail tip position was not associated with worse subjective function.ConclusionsPatella baja in patients after tibial intramedullary nailing via an infrapatellar/transtendinous approach, is associated with worse subjective function and increased pain.

Prevalence of Individual Differences in Tibial Torsion: A CT-Based Study.

To measure baseline bilateral tibial torsion in a cohort of uninjured patients to assess for a difference in torsion between sides. Consecutive bilateral lower extremity CT angiography scans from 229 patients without tibial or fibular pathology were collected and reviewed. Torsion of each tibia was measured by two independent reviewers, and individual differences in torsion were calculated. On average, patients have a 6.0° difference in tibial torsion between sides. A difference of greater than 10° was present in 18% of patients. Across the cohort of patients, the right tibia was on average 4.4° more externally rotated than the left. In patients with a greater than 5° difference, the right tibia was more externally rotated than the left in 85% of cases. Tibial torsion did not correlate with age or sex. Differences in tibial torsion are common and should be considered during intramedullary nailing of tibial fractures. When a difference in torsion is present, external torsion of the right tibia when compared with the left occurs predominantly. Prognostic level IV.

Pulsed electromagnetic fields after intramedullary nailing of tibial fractures: a case control study.

To compare clinical and functional outcomes of two groups of patients undergoing reduction and nailing fixation for diaphyseal fractures of the tibia with (PEMF group) and without (control group) post-operative pulsed electromagnetic field (PEMF) application. This is a retrospective study on 50 patients (mean age 43.3years, 28 males and 22 females) with diaphyseal tibial fractures managed between 2017 and 2019. Twenty-five patients underwent reduction, nailing fixation, and PEMF application post-operatively (PEMF group) and 25 patients underwent nailing fixation. Radiographic imaging assessment was performed every month until fracture healing had been evident. Use of analgesics, fracture healing time, post-operative lower limb alignment, and post-operative complications were recorded. Patients were asked about return to preinjury activity. All patients were assessed at 3months and at an average follow-up of 13months. The VAS scale and Johner-Wruhs criteria were used for pain assessment and functional recovery, respectively. Comparing groups, VAS values were significantly lower in the PEMF group at threemonths and comparable at oneyear. The patients in the PEMF group took an average of 4.1months to resume their preinjury activities, and control patients took an average of 5.3months (P < 0.0001). According to the Johner-Wruhs score, the effective rate was 100% (25/25) in the PEMF group and 92% (23/25) in the control group (P = 0.14). PEMF application after intramedullary nailing is safe and reduces post-operative pain, use of analgesics, and the time of healing fracture. At oneyear, there is no difference in outcome measures, regardless of PEMF application.

Comparison of Medial Parapatellar and Transpatellar Tendon Approach in Intramedullary Interlocking Nailing for Tibial Fracture: A Retrospective Analysis

IntroductionTibial fractures are one of the most common traumatic fractures, particularly in automobile accidents. Percutaneous reduction with conventional reduction forceps and un reamed intramedullary nailing, transpatellar, and medial parapatellar tendon approaches are all used, but tibial intramedullary nails are still primarily inserted through a transpatellar tendon splitting or medial parapatellar tendon approach.ObjectiveThe aim and objectives of this study are to assess the mean pain score after nailing for a tibial fracture using a medial parapatellar versus a transpatellar tendon method retrospectively in order to enhance operational planning.Materials and methodsThis is a retrospective study that took place in a UK level 1 trauma center. Data from 60 patients were included between February 2019 and February 2020. An equal number of patients were selected for both approaches to maintain accuracy. The advanced trauma life support (ATLS) protocol was used to handle all of the patients in both groups in order to rule out any other injuries or fractures, after which they were scheduled for surgery after stabilization. They were subsequently evaluated during a three-month follow-up in an outdoor clinic, where they were given a pain score using the visual analogue score (VAS) while moving their knee joints. The mean pain score was differentiated by age, gender, body mass index (BMI), injury side, and injury type.ResultsPatients were divided into groups based on their ages. Patients in the transpatellar tendon group were 32.83±5.13 years old, whereas those in the medial parapatellar tendon group were 31.4 ±5.42 years old. The gender distribution of the patients revealed that the majority of the patients in both groups were male. In both groups, the left side was the most usually affected. The difference between the two groups' mean pain scores at three months was substantially lower in the medial parapatellar approach (p=0.005).ConclusionFor patients having intramedullary nailing for tibial fractures, the medial parapatellar route is associated with a lower mean pain score than the transpatellar route. As a result, we may use this method in these individuals regularly.

Lateral position: a friendly surgical position for intramedullary nailing of tibial shaft fractures via infrapatellar approach

BackgroundThe conventional infrapatellar approach to intramedullary nailing of tibial fractures adopts the supine high-flexion knee position. However, this has disadvantages including difficulty in obtaining the proximal tibial anteroposterior view during intraoperative fluoroscopy, prolonged duration of fluoroscopy. Accordingly, the present study investigated the utility of the lateral position in the infrapatellar approach to intramedullary nailing of tibial shaft fractures.MethodsThe present study was a retrospective analysis of 112 patients who sustained closed tibial shaft fractures and treated with intramedullary nailing via the infrapatellar approach. Patients were divided into two groups according to surgical position: lateral or supine. The demographic and clinical data were collected and analyzed.ResultsThere were 54 patients in the lateral and 58 in the supine position groups. The duration of surgery and fluoroscopy was shorter in the lateral group than the supine group (p < 0.05). Blood loss during surgery was lower in the lateral compared with supine position group (p < 0.05). The malunion rate was lower in the lateral position group as compared with the supine position group (p < 0.05); moreover, fewer surgical assistants were needed than in the supine group (p < 0.05). There were no significant differences in fracture healing time, other complications between the two groups (p > 0.05).ConclusionsThe lateral position was a more convenient choice for intramedullary nailing of tibial shaft fractures via infrapatellar approach.

Prognostic factors for predicting health-related quality of life after intramedullary nailing of tibial fractures: a randomized controlled trial.

AimsUsing tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery.MethodsThe Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trial examined adults with an open or closed tibial shaft fracture who were treated with either reamed or unreamed intramedullary nails. HRQoL was assessed at hospital discharge (for pre-injury level) and at 12 months post-fracture using the Short Musculoskeletal Functional Assessment (SMFA) Dysfunction, SMFA Bother, 36-Item Short Form 36 (SF-36) Physical, and SF-36 Mental Component scores. We used multiple linear regression analysis to determine if baseline and surgical factors, as well as post-intervention procedures within one year of fracture, were associated with these HRQoL outcomes. Significance was set at p < 0.01. We hypothesize that, irrespective of the four measures used, prognosis is guided by both modifiable and non-modifiable factors and that patients do not return to their pre-injury level of function, nor HRQoL.ResultsFor patient and surgical factors, only pre-injury quality of life and isolated fracture showed a statistical effect on all four HRQoL outcomes, while high-energy injury mechanism, smoking, and race or ethnicity, demonstrated statistical significance for three of the four HRQoL outcomes. Patients who did not require reoperation in response to infection, the need for bone grafts, and/or the need for implant exchanges had statistically superior HRQoL outcomes than those who did require intervention within one year after initial tibial fracture nailing.ConclusionWe identified several baseline patient factors, surgical factors, and post-intervention procedures within one year after intramedullary nailing of a tibial shaft fracture that may influence a patient’s HRQoL.Cite this article: Bone Jt Open 2021;2(1):22–32.

Intramedullary Nailing of Paediatric Tibial Fractures: Comparison between Flexible and Rigid Nails.

To describe patient characteristics and to compare outcomes of children undergoing rigid intramedullary nailing of tibial fractures as compared with those operated on using elastic intramedullary nailing. A retrospective review of 26 children who have undergone flexible intramedullary nailing of tibial fractures and 30 children with rigid nailing at our university hospital between 2008 and 2017. The patient charts and radiographs were evaluated to identify demographic characteristics and several variables were measured preoperatively, as well as 6-12 weeks postoperatively in addition to final follow-up radiographs. Twenty-six patients (26/26, 100%) treated with a flexible nail and 14 patients (14/30, 46.7%) treated with a rigid nail had open proximal tibial physis (p < 0.001). An acceptable postoperative alignment was obtained in 20 patients (20/26, 76.9%) in the elastic stable intramedullary nail group and in 29 patients (29/30, 96.7%) in the rigid group (p = 0.026). Some complications occurred in four patients (4/26, 15%) in the elastic stable intramedullary nail population and seven patients (7/30, 23%) in the rigid intramedullary nail population (p = 0.46). Malunion occurred in six patients (6/26, 23%) in the elastic stable intramedullary nail group and in none of the patients treated with a rigid intramedullary nail (p = 0.005). Younger children with tibial fractures who weight 50 kg or less and with proximal tibial growth plates wide open can be treated with elastic stable intramedullary nail while more mature adolescents benefit from rigid intramedullary nailing.

Systematic Review and Analysis of the Quality of Randomized Controlled Trials Comparing Reamed and Unreamed Intramedullary Nailing of Tibial Fractures.

To evaluate the quality of research and reporting of randomized controlled trials comparing the use of reamed and unreamed intramedullary nails for tibial fractures with validated scoring systems. PubMed using the search terms "tibia" AND "reamed OR unreamed" AND "intramedullary OR nail." Filters were applied for the years 1991-2019, full articles, human subjects, and English language. Inclusion criteria were (1) prospective and randomized trials, (2) studies reported >80% follow-up, and (3) articles amenable to scoring with the chosen scoring systems. Exclusion criteria were (1) skeletally immature patients or (2) incomplete data sets. Articles were assessed with the Coleman Methodology Score, the Consolidated Standards of Reporting Trials systems, and Cowan's Categorical Rating by 2 independent observers. Scores for individual articles were averaged for the 2 observers. The total and subcategory scores for all included articles were also averaged with SD from both observers. Categories from the 2 grading systems with deficient reporting were measured as a percentage based on grading from both observers. Data were analyzed using kappa statistic and correlation coefficient to assess agreement and reliability. All included articles supported the use of reamed tibial intramedullary nails, but the overall quality of the literature fell in the middle of both the modified Coleman Score and Consolidated Standards of Reporting Trials grading scheme ranges despite being Oxford Level 1. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Complications and subsequent surgery after intra-medullary nailing for tibial shaft fractures: Review of 8110 patients

BackgroundIntramedullary nailing of tibial shaft fractures has been common practice for decades. Nevertheless, complications occur frequently, and subsequent surgery is often required. To improve our understanding on how we may improve trauma care for patients with tibial shaft fractures, this study systematically reviewed all currently available evidence to assess the incidence of complications and rate of re-operations following intramedullary nailing of traumatic tibial fractures. MethodsTrip Database, Medline, Scopus and Cochrane Library were searched on September 7th, 2018. Searches were limited to English studies published after January 1st, 1998. Studies were included if authors included more than 50 patients treated with intramedullary nailing for traumatic tibial fractures. Inclusion of studies and critical appraisal of the evidence was performed by two independent authors. Incidence of complications and rate of re-operations were reported with descriptive statistics. ResultsFifty-one studies involving 8110 patients treated with intramedullary nailing for traumatic tibial fractures were included. Mean age of patients was 37.5 years. The most frequent complication was anterior knee pain (23%), followed by non-union (11%). Eighteen percent of patients required at least one subsequent surgery. The most frequent indication of subsequent surgery was screw removal due to pain or discomfort (9%). Dynamization of the nail to promote union was reported in 8% of the cases. Nail revision and bone-grafting to promote union were applied in 4% and 2% respectively. Discussion & ConclusionPatients treated with intramedullary nailing for tibial fractures need to be consented for high probability of adverse events as anterior knee pain, subsequent surgical procedures and bone healing problems are relatively common. However, based on current data it remains difficult to identify specifiers and determinants of an individual patient with specific fracture characteristics at risk for complications. Future studies should aim to establish patient specific risks models for complications and re-operations, such that clinicians can anticipate them and adjust and individualize treatment strategies.

Is electromagnetic guidance system superior to a free-hand technique for distal locking in intramedullary nailing of tibial fractures? A prospective comparative study.

Intramedullary nailing (IMN) technique is the gold standard for the treatment of closed fractures of the lower extremity long bones. For orthopedic surgeons, one of the most important problems in IMN procedures is the fixation of distal locking screws (DLS). Accurate and rapid placement of DLSs with minimal radiation exposure is crucial. In this study, we aimed to compare the results of two different distal locking methods concerning surgery duration and radiation exposure in patients who underwent osteosynthesis of tibia fractures with IMN. In this prospective study, the results of 56 patients who met the inclusion and exclusion criteria from 72 patients were evaluated. Patients were divided into two groups according to the distal screwing method. Group 1 (n=29) comprised patients who used free-hand technique (FHT) for distal locking, while Group 2 (n=27) consisted of patients who used electromagnetic guidance system (EMGS) for distal locking. Demographic and medical data of the patients, duration of surgery time, amount of bleeding, total fluoroscopy counts, the time elapsed for distal locking, the measure of radiation exposure, number of attempts for distal screw locking, incorrect screw placements, complications and follow-up time were recorded. The groups were compared concerning demographic data and clinical results. There was no statistically significant difference between the groups about gender and side (p=0.928 and p=0.432, respectively). The mean age in Group-1 was higher than that of Group-2, and the difference was statistically significant (p=0.012). However, there was no statistically significant difference in length of hospital stay in Group-1 (p=0.140). On the other hand, in Group-2, the number of distal shots, fluoroscopy duration, effective radiation dose and operation duration were lower compared to Group-1, although this difference was not statistically significant (p=0.057, 0.073, 0.058 and 0.056, respectively). Failure was encountered in distal locking during the first attempt in three cases in Group-1 and in two cases in Group-2. Aseptic nonunion was observed in one patient in both groups. Both the FHT distal screwing technique and the EMGS distal screwing technique are highly effective methods for distal locking. The duration of operation, the duration of the fluoroscopy and radiation exposure were similar. FHT can be preferred for distal locking in conventional intramedullary nail applications, as it is effective, easy and inexpensive.

Changing practice patterns: flexed versus semi-extended positioning for tibial nailing

Background: Recent studies have demonstrated several benefits to semi-extended leg position for intramedullary nailing (IMN) without increased complications. The purpose of this study was to evaluate how surgeon preference for flexed versus semi-extended positioning has changed over time. Methods: We distributed an anonymous online survey to orthopaedic surgeons via the Orthopaedic Trauma Association (OTA) website. We compared surgeon demographics and preferred leg positioning for tibial nailing. Results: Twenty-seven percent of surgeons reported substantial experience (&gt;50% of cases) with semi-extended positioning during training, while 49% of surgeons preferred semi-extended nailing in current practice (P&lt;0.001). Surgeons who practiced in the U.S. (P&lt;0.001) or who completed a trauma fellowship (P&lt;0.05) were more likely to have had exposure to the semi-extended positioning during training. Surgeons who practiced in the U.S. (P&lt;0.001), supervised residents (P&lt;0.05) or had completed a trauma fellowship (P&lt;0.01) were significantly more likely to currently prefer the semi-extended positioning. Surgeons in the U.S. (P&lt;0.01), or who supervised residents (P&lt;0.05) were more likely to have changed from the hyper-flexed to semi-extended position. Facilitating reduction in proximal fractures was the most cited reason for switching to the semi-extended position (28%). Conclusions: Semi-extended has become the preferred position during intramedullary nailing of tibial fractures among U.S. surgeons, those supervising residents, or those completing a trauma fellowship. Flexed nailing remains the preferred technique for international surgeons. Further investigation of extended nailing techniques is necessary. However, given its preference for the conventional flexed nailing, the international community may benefit from further educational interventions, demonstrating the benefits of extended nailing.

Suprapatellar tibial nailing: a learning curve analysis.

The suprapatellar approach for intramedullary nailing of tibial fractures is gaining popularity with reported improved patient outcomes when compared to infrapatellar techniques. The aim of this study was to investigate the learning curve of the suprapatellar technique using radiation exposure as an outcome measure. Data were analysed from a prospectively collected database over a 3-year period at a Major Trauma Centre in the UnitedKingdom. 83 study patients with an acute isolated extra-articular fracture of the tibia treated with intramedullary tibial nailing were included. Cases requiring additional intra-operative procedures were excluded. Four consultant trauma surgeons with no previous experience of the suprapatellar technique used this approach for 40 consecutive operations. Six consultant trauma surgeons used the infrapatellar approach for 43 patients and acted as a control group. Patient demographics, fluoroscopy time and radiation dose area product (DAP) were collected for each operation. A segmented linear regression modelling method was employed to analyse learning. Fluoroscopy time and DAP per surgeon showed no evidence of a learning curve when using a suprapatellar tibial nailing technique in group or individual analysis. Fluoroscopy time and DAP were stationary in the infrapatellar group analysis, confirming the absence of time-dependent trends over the study period. Consultant trauma surgeons experienced no significant learning-related increase in radiation exposure when introducing a suprapatellar technique for intramedullary nailing of uncomplicated tibial fractures. Future work is required to investigate the effects of learning on other outcome measures.

Predictors of mechanical complications after intramedullary nailing of tibial fractures

IntroductionIntramedullary (IM) nailing is the gold standard treatment for tibial shaft fractures, but can be associated with various mechanical complications, including delayed union. HypothesisWe believe that complications do not occur randomly, but in certain conditions that contribute to their development. Risk factors likely to predict delayed union can be identified to support prevention. Materials and methodsA cohort of 171 fractures treated by IM nailing between 2005 and 2015 was reviewed retrospectively. Independent variables included intrinsic, patient-related factors and extrinsic factors such as those related to the fracture or surgery. A multiple logistic regression model was used to determine which factors can predict each type of complication. ResultsDelayed union occurred in 22.8% of patients. Smoking and high-energy trauma were risk factors. Hardware breakage was significantly reduced (p<0.05) when the nail diameter was greater than 10mm. A nail diameter/reamer diameter ratio outside the recommended limits (0.80–0.99) was more likely to be associated with screw failure. Diabetes is a risk factor for hardware migration, which itself is associated with other complications. DiscussionNonunion is the most common complication after IM nailing of tibial shaft fractures. Smoking cessation after a fracture is necessary in our opinion, even if the literature is ambivalent on this aspect and stopping to smoke once the fracture occurs may not be sufficient to prevent a poor outcome. Use of a nail diameter/reamer diameter between 0.80 and 0.99 favors union and prevents hardware breakage. Hardware migration in a diabetic patient may be a warning sign of other types of complications. Level of evidenceRetrospective cohort study. Level IV.

A study on complications of expert tibial intramedullary nailing of tibial fractures

The mechanical behaviour of IM nails depends on both material and geometry of the design. 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 comminuted fractures, as there tends to be shortening or displacement of such fractures around these small nails. Twenty five patients with proximal 1/3rd and distal 1/3rd tibia fractures were selected for the study. In total number of 25 patients admitted, there were 17 males (68%) and 8 females (32%). There were 20 closed fractures (80%) and 5 open fracture (20%) (GA type I-3, GA type II-2). The average range of motion in the knee joint was 135.6 degree, full ankle motion was observed in 20 patients. One patient showed a loss of >250 of motion at ankle compared to the normal side while 4 patients showed < 250 of loss of joint motion. One case (4%) of deep infection and implant failure was noted in the present study. Two patients (8%) showed a superficial soft tissue infection. One case (4%) of malunion was found with an anteroposterior angulation of 10 degrees, one case (4%) with a distal 3rd showed a shortening of < 1cm.No cases of significant rotational deformities and varus or valgus angulation deformities was noted.