Nailing Of Distal Tibial Fractures Research Articles

Improved weight bearing during gait at 6 weeks post-surgery with an angle stable locking system after distal tibial fracture

BackgroundFunctional recovery after intramedullary nailing of distal tibial fractures can be monitored using ipsilateral vertical ground reaction forces (vGRF), giving insight into recovery of patients’ gait symmetry. Previous work compared patient cohorts to healthy controls, but it remains unclear if these metrics can identify treatment-based differences in return to function post-surgery. Research questionIs treatment of a distal tibial fracture with intramedullary nailing with an angle stable locking system (ASLS) associated with higher ipsilateral vGRF and improved symmetry compared to conventional intramedullary nailing at an early time point? MethodsThirty-nine patients treated with ASLS intramedullary nailing were retrospectively compared to thirty-nine patients with conventional locking. vGRFs were collected at 1, 6, 12, 26, and 52 weeks post-surgery during standing and gait. Discrete metrics of ipsilateral vGRF (maximal force, impulse) and asymmetry were compared between treatments at each time point. Time-scale comparisons of ipsilateral vGRF and lower limb asymmetry were additionally performed for gait trials. Mann-Whitney Test or a two-way analysis of variance tested discrete comparisons; statistical non-parametric mapping tested time-scale data between treatment groups. ResultsDuring gait, ASLS-treated patients applied more load on the operated limb (17–38% stance, p = 0.015) and consequently loaded limbs more symmetrically (8–37% stance, p = 0.008) during the loading response at 6 weeks post-surgery compared to conventional IM treatment. Discrete measures of symmetry at the same time point identified treatment-based differences in maximal force (p = 0.039) and impulse (p = 0.012), with ASLS-treated patients exhibiting more symmetry. No differences were identified in gait trials at later time points nor from all standing trials. SignificanceDuring the initial loading response of gait, increased ipsilateral vGRF and improved weightbearing symmetry were identified in ASLS patients at 6 weeks post-surgery compared to conventional IM nailing. Early and objective metrics of dynamic movement are suggested to identify treatment-based differences in functional recovery.

Suprapatellar vs Infrapatellar Approaches for Intramedullary Nailing of Distal Tibial Fractures: A Prospective Observational Study

Introduction: Intramedullary nailing is a commonly employed procedure for treating distal tibial fractures. The two primary approaches for this procedure include the suprapatellar and infrapatellar techniques. Despite their widespread use, there is ongoing debate about the relative merits and drawbacks of these two approaches. Aim of the Study: The aim of this study was to assess the comparison between suprapatellar and infrapatellar approaches for intramedullary nailing of distal tibial fractures. Methods: This cross-sectional study was conducted in Department of Orthopaedics Surgery, Brahmanbaria Medical College Hospital, Brahmanbaria, Bangladesh, during the period from December 2020 to December 2022. Total 120 patients with intramedullary nailing of distal tibial fractures were included in this study. All the patients were divided into two groups; Group A comprised of 60 patients treated by suprapatellar approach and Group B comprised of patients treated by infrapatellar approaches. Result: For age, the mean age in Group A is 42.3 years (SD± 9.8 years), and in Group B it is 44.7 years (SD±10.3 years). In terms of sex, male predominance was seen in both groups. Surgical characteristics like surgical time (68.5 vs 74.2 mins), blood loss (58.4 vs 63.7 ml), and fluoroscopy number (15.7 vs 18.9) were significantly less in Group A. Post-operatively, Group B reported more pain (VAS score: 27.1 vs 18.7), while Group A had better range of motion (18.3 vs 17.1) and knee functionality (Lysholm score: 84.6 vs 80.9). Group B showed better foot and ankle functionality (AOFAS score: 94.4 vs 91.3). Fracture healing time was similar (24.5 vs 24.7 months). Fewer patients in Group A experienced complications like fracture deformity, malalignment, and surgical site infections. Conclusion: The suprapatellar approach may be the preferred nailing technique for treating distal tibial fractures compared with infrapatellar approach.

Does the distal nail position impact the rates of misalignment and bone union in distal tibial fractures?

This retrospective study aimed to assess the impact of distal nail placement on misalignment and healing rates in distal tibial fractures. We reviewed all patients with distal tibial fracture treated with intramedullary nailing between 2015 and 2021, and a minimum follow-up of 12months. Distal nail positioning was determined according to the Triantafillou zones. We related these positioning zones to misalignments (alignment ≥ 3°) and too bony union disorders (delayed union, non-union). Out of the 62 patients included, 56 (90.3%) show bone union without additional procedure, 3 (4.8%) with dynamization, and 3 (4.8%) showed non-union. Twenty-one (33.8%) presented misalignment, with valgus in the coronal plane being the most frequent (76.19%). In patients with and without misalignment, the most frequent distal nail position was 2-2 in 47.6% and 80.5%, respectively (p = 0.01). In multivariate analysis, distal nail positioning in the 2-2 zone showed a significant protective effect against misalignment (OR 0.18; p = 0.018), while nail positioning in the 3-2 zone generated a significant risk of misalignment (OR 18.55; p = 0.009). In intramedullary nailing of distal tibial fractures, distal positioning of the nail slightly lateral to the center of the talus in the coronal plane and slightly posterior in the sagittal plane (zone 2-2) allows high alignment percentages to be obtained. Positioning medial to this point in the coronal plane (zone 3) is associated with more significant misalignment and should be avoided.

A comparative study of functional and radiological outcome in the management of distal tibia fractures treated by intra medullary nailing and minimally invasive locking plate

Aim: To compare functional and radiological outcome in the management of distal tibia fractures treated by intra medullary nailing and minimally invasive locking plate. Material and Method: This perspective observational study was undertaken in the Department of Orthopaedic Surgery of SRMS-IMS, Bareilly for a period of 18 months from November 2019 to April 2021 among patients with DISTAL TIBIAL FRACTURE. According to the hospital record, 30 patients of similar condition were treated by intra medullary nailing or minimally invasive locking plate last year. The study participants were split into two groups: those who received intramedullary interlock nailing (Group 1) and those who received a minimally invasive locking plate (Group 2). All patients who underwent intramedullary nailing or minimally invasive plating were evaluated using the American Orthopaedics Foot and Ankle Society score. Results: Mean duration of surgery (in min) was 64.19±7.91 and 72.36±6.23 in group 1 and 2 respectively. After 6 months, excellent radiological union was revealed among 50% and 56.25% of the subjects in group 1 and 2 respectively. When AOFAS score was compared using chi square test among group 1 and group 2 at 3 and 6 months, it was found to be statistically insignificant as p>0.05 in our study. Conclusion: Intramedullary nailing in distal tibial fractures allows for early mobilisation and is a simpler, less expensive and less complication-prone procedure. In cases where the fracture is very close to the ankle mortise and is associated with a greater rate of wound complications, plating is preferred.

Intramedullary expert tibial nailing of distal tibial fractures: Functional outcomes with a midterm follow-up

Intramedullary expert tibial nailing of distal tibial fractures: Functional outcomes with a midterm follow-up

Is device-assisted reduction prior to semi-extended intramedullary nailing of distal tibial fractures necessary?

IntroductionTraditional methods of nailing distal tibial fractures have an unacceptable risk of mal-alignment due to difficulty in obtaining and maintaining reduction intra-operatively. Methods to obtain and maintain reduction when nailing these fractures, and therefore reducing the risk of Mal-alignment include modified external fixators, distractors and commercial reduction tools. Semi-extended intramedullary nailing of distal tibial fractures via a supra-patellar approach is now being used more commonly. The aim of this study was to assess whether a commercial reduction device (Staffordshire Orthopaedic Reduction Machine − STORM, Intelligent Orthopaedics, Stafffordshire, UK) is necessary to reduce the risk of mal-alignment in patients undergoing semi-extended nailing for distal tibial fractures. MethodologyA case-control study was conducted in 20 patients who had STORM-assisted reduction of distal tibial fractures prior to intramedullary nailing and 20 controls without STORM. The control group was matched for age, sex, fracture type (AO/OTA), ASA and gender. All patients had an intramedullary nail (IMN) using the semi-extended system. Primary outcome measures were coronal and sagittal mal-alignment. Secondary outcome measure was unplanned return to theatre for complications and problems with fracture healing. ResultsThere was no difference in post-operative mal-alignment in both groups. There was no significant difference in time to union in both groups Both groups had equal number of patients requiring unplanned return to theatre. The STORM group was associated with a significantly increased operative time [p=0.007, 130.3min (SD 49.4) STORM vs 95.6 mins (SD 22.9) Control]. ConclusionIntraoperative use of STORM significantly increases operative time with no difference in outcome. The superior orthogonal views and manual control obtained during semi-extended nailing via a supra-patellar approach obviate the need for additional methods: of intraoperative reduction for this fracture group.

Outcomes After Intramedullary Nailing of Distal Tibial Fractures.

To determine outcomes in the treatment of distal tibial fractures treated with intramedullary nails. Retrospective analysis. Level I trauma center with follow-up in a private orthopaedic practice. Radiographic determination of alignment, nonunion, and malunion, clinical outcome (range of motion, and implant-associated complaints), wound complications, and fibular fixation. A total of 105 patients with OTA/AO type A and C tibial fractures (<11 cm from the joint line) treated with intramedullary nailing. Distance of the fracture from the joint line averaged 6.1 cm (range, 0-11). Mean follow-up was 25.6 months (range, 12-74). Nonunion occurred in 20 (19%) fractures and were significantly associated with open fractures (P = 0.012), wound complications (P < 0.001), and the need for fibular fixation (P = 0.007). Sagittal plane alignment averaged 2.5 degrees (±4.4) valgus. Malunion occurred in 25 (23.8%) fractures and again were significantly associated with open fractures (P = 0.045). Fifty (47.6%) patients had implant-related pain, which resolved in 27 (54.0%) after removal. Intramedullary nailing of distal tibial fractures is a suitable treatment option. Acceptable alignment and range of motion can be achieved. Both nonunions and malunions were significantly associated with open fractures, wound complications, and fibular fixation. Implant removal was needed in 25% of cases. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of distal interlocking screw number and position after intramedullary nailing of distal tibial fractures: a biomechanical study simulating immediate weight-bearing.

To quantify the changes in biomechanical stability conferred by the addition of a single medial blocking screw or a single bicortical interlocking screw to 2 existing distal points of screw fixation in a distal tibial fracture model repaired with intramedullary nailing. After simulation of a distal tibial metaphyseal fracture, 21 synthetic tibiae were repaired with an intramedullary nail and: (1) two bicortical locking screws placed in the 2 most distal screw holes (IM-L2); (2) three distal bicortical locking screws (IM-L3); and 2 distal locking screws and a single blocking screw positioned in the sagittal plane on the medial aspect of the nail (IM-L2B). The specimens were tested under combined cyclic axial and torsional loading for up to 16k cycles. The former was stepwise increasing, whereas the latter was with constant amplitude in internal rotation. All constructs survived 12k cycles without hardware deformation or failure. IM-L3 constructs displayed the highest baseline axial stiffness at the beginning of the test (1130.9 ± 246.9 N/mm), which was significant compared with the IM-L2 construct (701.8 ± 189.57 N/mm, P = 0.004). No significant difference in baseline axial stiffness was identified between the IM-L3 and IM-L2B constructs (881.1 ± 182.4 N/mm, P = 0.125). Relative varus interfragmentary deformation at baseline was smaller in the IM-L3 treatment group (1.3 ± 0.3 degrees) relative to the IM-L2 group (2.4 ± 0.7 degrees, P = 0.012). No differences in torsional rigidity or relative interfragmentary torsional deformation were identified between groups (P > 0.168). Failure was breakage or backout of the distal bicortical screws, fracture of the distal fragment, or proximal screw breakage. There was no significant difference in number of cycles to failure between instrumentation groups (IM-L2: 14,345 ± 1438 cycles; IM-L3: 15,634 ± 626 cycles; and IM-L2B: 14,862 ± 1511 cycles, P = 0.184). Results suggest that each of the constructs tested here may be a biomechanically viable option allowing for immediate weight-bearing after fixation of fractures of the distal third of the tibia. The addition of a single bicortical interlocking screw to create 3 points of distal fixation improves construct stiffness while reducing interfragmentary motion relative to 2 interlocking points of screw fixation with or without a blocking screw.

Intramedullary Nailing of Distal Tibial Fractures with Percutaneous Reduction by Pointed Reduction Forceps

Intramedullary Nailing of Distal Tibial Fractures with Percutaneous Reduction by Pointed Reduction Forceps

Unreamed intramedullary nailing in distal tibial fractures

Unreamed nailing has gained acceptance in the treatment of diaphyseal long bone fractures, especially in cases with polytrauma or high-energy injuries. Its application in distal tibial fractures, however, remains controversial. In this study, 101 distal tibial fractures treated using closed unreamed nailing were reviewed after a mean follow-up of 32 months. There were 59 type A und 42 type B fractures. The most common fracture pattern was the A1 spiral fracture (n = 40) followed by the B2 wedge fracture (n = 18). Intra-articular extension was encountered in 14 cases. One-fourth of the patients (n = 24) had open injuries. Forty-seven patients had additional injuries, and nearly one-third of them were polytraumatised. Union occurred after a mean time of 23.9 (range, 11-134) weeks. There were 13 cases of delayed union and seven non-unions; all healed eventually with additional surgery in only six fractures. Malunion was seen in 12 cases (five valgus, two varus and five external torsion), ten of which were associated with unplated fibular fractures. Three fractures (two open) were treated for deep infection. The most common complication seen was fatigue failure of the locking screws (27 cases). Unreamed nailing of distal tibial fractures is associated with a rather high rate of bone healing complications and locking screw failure. The decision for its use in the notoriously challenging fractures of this segment should be critically considered.

Distal Tibial Fractures: Intramedullary Nailing.

The tibia is an exposed bone with vulnerable soft tissue coverage and is therefore predisposed to local soft tissue problems and delayed bone healing. The objective in distal tibial fracture treatment is to achieve stable fixation patterns with a minimum of soft-tissue affection. Thus, the risk of soft tissue breakdown and bone healing complications is more likely related to open reduction and plating. Percutaneous, minimally invasive intramedullary nailing is a proven fixation mode for fracture stabilization in tibial shaft fractures. Anticipating the pitfalls, intramedullary nailing meets the requirements of the method of choice in distal tibial fracture fixation. In conclusion, intramedullary nailing of distal tibial fractures is a reliable method of fixation, possessing the advantages of closed reduction and symmetric fracture stabilization of an area with a delicate soft tissue situation, but prospective randomized trials are needed to compare modern intramedullary fracture fixation with modern plate fixation in distal tibial fractures.

Evaluation of interlocking intramedullary nailing in distal tibial fractures and nonunions

The aim of this study was to evaluate the results of interlocking intramedullary nailing in the treatment of extra-articular distal tibial fractures and nonunions. The study included 45 patients (mean age 42 years; range 27 to 52 years) who were treated with interlocking intramedullary nailing for distal tibial fractures (n=35) and nonunions (n=10). Of 35 fractures, 31 were closed and four were open. The fractures were AO A1 (n=27), A2 (n=6), and A3 (n=2). In addition, two patients had medial, and 14 patients had lateral malleolus fractures. A Gross-Kempf (Howmedica) nail was used in 38 patients and an Expert nail (Synthes) was used in seven patients. Dynamic nailing was performed in 22 patients and static nailing was performed in 23 patients. No grafting was used. The patients were assessed clinically and radiographically within a mean follow-up period of 37 months (range 24 to 60 months). Union was achieved in all the patients within a mean of 4.6 months (range 3 to 7 months). Dynamization was required in three patients. The mean time to union was 4.4 months (range 3 to 6 months) with dynamic nailing and 4.8 months (range 3 to 7 months) with static nailing. Complications were not serious. Transient peroneal nerve palsy developed in one patient (2.2%). Knee pain was seen in four patients (8.9%) due to the protrusion of the nail and it disappeared after removal of the nail. Five patients (11.1%) had limitation of ankle movements in a range of 5 to 10 degrees. None of the patients had restriction in knee motion. Intramedullary interlocking nailing is a reliable method of treatment for distal tibial fractures and nonunions, with a high rate of union and low complication rate.

Treatment of distal tibial fractures: plate versus nail

A study of 24 patients who sustained an extra-articular fracture of the distal third of the tibial shaft was performed to determine the effect of the type of treatment, open reduction and internal fixation (ORIF) or closed reduction and intramedullary (IM) nailing, on the occurrence of malalignment. All patients were treated in our clinic between 1993 and 2001 for a fracture in the distal third of the tibia. Twelve patients treated with ORIF were matched to 12 patients treated with IM nailing, with regard to gender, age decade, and the AO classification of the fracture. The group treated with IM nailing was assessed after a mean 6.0 years versus ORIF after a mean of 4.5 years. Two patients treated with ORIF versus six patients treated with IM nailing had a malalignment of the tibia. Furthermore, we found no difference with regard to time to union, non-union, hardware failure or deep infections between ORIF and IM nailing. Our results suggest that control of alignment is difficult with IM nailing of distal tibial fractures. For optimal alignment we advise considering the use of ORIF for closed and type I open extra-articular fractures in the distal third of the tibia.

Precise Positioning of Unreamed Solid Nails in Short Distal Tibial Fragments With Percutaneous K-Wires

The palisade technique is an effective tool to prevent malalignment in unreamed nailing of distal tibial fractures and for precise repositioning of the nail in corrective surgery.

Intramedullary Nailing of Distal Tibial Fractures: A Technique to Prevent Malalignment

This article presents a technique for treating distal tibial fractures using an interlocking syndesmosis screw in the distal portion of the intramedullary nail to prevent malalignment

Treatment of distal metaphyseal tibia fractures with involvement of the ankle by combination of locked intramedullary nailing and covered screw osteosynthesis

Fractures of the distal metaphysis of the tibia often include an extension into the ankle. Intramedullary nailing combined with covered screw osteosynthesis should reduce the high incidence of soft tissue and ankle problems and should be an alternative to open plate fixation, with good ultimate functional outcome. Between January 1993 and December 1995, a prospective study on 49 patients with distal metaphyseal tibia fracture and involvement of the ankle was performed. All the fractures were treated with intramedullary nailing combined with covered screw osteosynthesis, and plate fixation in cases of fibula fractures. There were 27 men and 22 women with an average age of 46.4 ± 12.7 years (range 21–90). In most studies of the use of intramedullary nailing in distal tibial fractures the classification has been inadequate. Therefore a new classification according to Robinson et al. (1995) was used: 10 fractures were type II B (20.4 %), 13 were type II C (26.5 %), and 26 patients suffered a combination of type II B and type II C (53.1 %). This fracture type was defined as type II D for use in this study. The severity of soft tissue injury was recorded using the Gustilo system in case of open (n = 19) and the Tscherne system in case of closed fractures (n = 30). In 31 patients distal tibia fracture was accompanied by a fracture of the fibula, which was first stablized using a plate. For reconstruction of the distal articular surface, covered screw osteosynthesis was done. At the next step intramedullary nails were inserted and were statically locked proximally and distally. From January 1993 to February 1994, the reamed AO standard nail was used. After introduction of the unreamed tibial nail (UTN) all fractures were treated by this implant. Full load on the operated leg was allowed after 8 weeks. Union of the fracture was assessed by standard radiological and clinical criteria. Misalignment was defined as more than 5 ° of angular rotation. Further surgery due to a valgus deformity in the ankle joint had to be done in three cases. There were no deep infections. Three patients had a superficial infection in the ankle area, but surgical debridement was not necessary. A leg shortening was found in 4 cases, but it was less than 1 cm in every case. Therefore, surgical correction was not done. Patients were reviewed at intervals of 2, 6, and 12 weeks, and after 6, and at least 12 months. All 49 patients were finally reviewed after an average time of 15.7 months (range 12–38). Bone fusion was reached 12.8 weeks (range 9–21) after the operative treatment. A specific assessment of the ankle symptoms was made using the score of Olerud and Molander (1984). In 29 patients excellent results were recorded. A satisfactory result was attained with 17 patients and just 3 patients were found to be unsatisfactory. Although proximity of distal tibia fracture to the ankle makes the treatment more complicated than for fractures of the tibial diaphysis, closed intramedullary nailing combined with covered screw fixation is a good alternative to open reduction and plate fixation. The major advantages are closed procedure and simplified interlocking techniques. Therefore, closed intramedullary nailing combined with covered screw fixation is a safe and effective method of managing this type of fracture.

Treatment of distal metaphyseal tibia fractures with involvement of the ankle by combination of locked intramedullary nailing and covered screw osteosynthesis

Fractures of the distal metaphysis of the tibia often include an extension into the ankle. Intramedullary nailing combined with covered screw osteosynthesis should reduce the high incidence of soft tissue and ankle problems and should be an alternative to open plate fixation, with good ultimate functional outcome. Between January 1993 and December 1995, a prospective study on 49 patients with distal metaphyseal tibia fracture and involvement of the ankle was performed. All the fractures were treated with intramedullary nailing combined with covered screw osteosynthesis, and plate fixation in cases of fibula fractures. There were 27 men and 22 women with an average age of 46.4 +/- 12.7 years (range 21-90). In most studies of the use of intramedullary nailing in distal tibial fractures the classification has been inadequate. Therefore a new classification according to Robinson et al. (1995) was used: 10 fractures were type II B (20.4%), 13 were type II C (26.5%), and 26 patients suffered a combination of type II B and type II C (53.1%). This fracture type was defined as type II D for use in this study. The severity of soft tissue injury was recorded using the Gustilo system in case of open (n = 19) and the Tscheme system in case of closed fractures (n = 30). In 31 patients distal tibia fracture was accompanied by a fracture of the fibula, which was first stabilized using a plate. For reconstruction of the distal articular surface, covered screw osteosynthesis was done. At the next step intramedullary nails were inserted and were statically locked proximally and distally. From January 1993 to February 1994, the reamed AO standard nail was used. After introduction of the unreamed tibial nail (UTN) all fractures were treated by this implant. Full load on the operated leg was allowed after 8 weeks. Union of the fracture was assessed by standard radiological and clinical criteria. Misalignment was defined as more than 5 degrees of angular rotation. Further surgery due to a valgus deformity in the ankle joint had to be done in three cases. There were no deep infections. Three patients had a superficial infection in the ankle area, but surgical debridement was not necessary. A leg shortening was found in 4 cases, but it was less than 1 cm in every case. Therefore, surgical correction was not done. Patients were reviewed at intervals of 2, 6, and 12 weeks, and after 6, and at least 12 months. All 49 patients were finally reviewed after an average time of 15.7 months (range 12-38). Bone fusion was reached 12.8 weeks (range 9-21) after the operative treatment. A specific assessment of the ankle symptoms was made using the score of Olerud and Molander (1984). In 29 patients excellent results were recorded. A satisfactory result was attained with 17 patients and just 3 patients were found to be unsatisfactory. Although proximity of distal tibia fracture to the ankle makes the treatment more complicated than for fractures of the tibial diaphysis, closed intramedullary nailing combined with covered screw fixation is a good alternative to open reduction and plate fixation. The major advantages are closed procedure and simplified interlocking techniques. Therefore, closed intramedullary nailing combined with covered screw fixation is a safe and effective method of managing this type of fracture.