Tibial Nail Research Articles

Intramedullary nailing of tibial shaft fractures in the semi-extended position using suprapatellar approach: A case series in Hong Kong

Introduction The objective of this case series is to evaluate the clinical outcome of patients with tibial shaft fractures treated by suprapatellar nailing at a 2-year follow-up and to review available literature concerning this approach. Method and material This is a retrospective single-centre case series to evaluate patients' post-operative status at 2-year intervals. Fifteen (15) patients underwent intramedullary nailing with a supra-patella approach during the year 2019–2020 and consented to participate in this case series. Patients were regularly followed up in the outpatient clinic and evaluated in terms of range of movement, walking status and radiologically with RUST score and tibia alignment. Their functional outcome was assessed by a questionnaire including OKS, VAS, and Kujula scores. Results At post-op 2 years intervals, all patients had radiologically healed fractures as evidenced by RUST score and tibia alignment within five degrees in the coronal and sagittal plane, the functional outcome of the suprapatellar approach was satisfactory in the visual analogue scale and various knee scores. All patients achieved a full range of movement and could walk unaided. Discussion Technical tricks and tips for the suprapatellar approach are discussed. Literature review showed satisfactory outcomes for intramedullary nailing for tibial shaft fracture in different parts of the world. Compared with the infra-patellar approach, the suprapatellar approach is superior in fracture alignment but has no significant difference in terms of pain, disability and range of movement. Potential risk of suprapatellar approach is discussed including possible cartilage damage and intra-articular sepsis. Conclusion There is a good clinical outcome of the suprapatellar approach to tibial nail radiologically and functionally. Results are in line with the literature review, which also showed that compared with the infra-patellar approach, the suprapatellar approach is associated with better alignment and less knee pain but no significant difference in range of movement and disability.

Comparison of retrograde and antegrade tibial intramedullary nail in the treatment of extra-articular distal tibial fractures.

The aim of this study was to compare the effectiveness of retrograde and antegrade intramedullary tibial nails (RTN and ATN) in managing extra-articular distal tibial fractures, addressing current controversies in surgical approaches. A retrospective analysis included 56 patients treated between December 2019 and August 2022 with either RTN (n = 23) or ATN (n = 33). Data on baseline characteristics, operative specifics, fluoroscopy usage, hospitalization duration, fracture healing times, time to full weight-bearing, distal tibial alignment, American Orthopedic Foot and Ankle Society (AOFAS) scores at final follow-up, and complications were evaluated and compared. Baseline characteristics were generally comparable and no significant differences except for fracture line lengths (RTN: 6.1 ± 1.9cm vs. ATN: 7.8 ± 1.6cm) were observed. Follow-up ranged from 12 to 20 months. No significant differences were observed in operative duration, hospital stays, coronal angulation of the distal tibial joint surface, or AOFAS scores at final follow-up. Intraoperative fluoroscopy was more frequent in the ATN group (9.5 ± 1.5) compared to RTN (8.3 ± 1.1) (P = 0.001). RTN showed shorter healing times (9.6 ± 1.2 weeks) and quicker return to full weight-bearing (12.9 ± 1.3 weeks) than ATN (10.6 ± 1.2 weeks and 13.9 ± 1.7 weeks, respectively). RTN complications included one delayed union, one superficial infection, and two ankle pain, while ATN complications comprised one delayed union, one superficial infection, seven anterior knee pain, and one malalignment. Despite higher complication rates with ATN, the differences were not statistically significant. For the treatment of extra-articular distal tibial fractures, both RTN and ATN are effective approaches. RTN may offer benefits such as reduced fluoroscopy use, accelerated healing, and earlier return to full weight-bearing compared to ATN.

Enoxaparin and Early Postoperative Tibial Nailing: Increased Nonunion Revision Rates.

To determine the association between postoperative enoxaparin use and the risk of requiring surgery for nonunion in patients treated with intramedullary nailing for midshaft fractures of the tibia. Retrospective cohort analysis. Data were sourced from the PearlDiver national database. Patients were identified through the PearlDiver database by using Current Procedural Terminology and International Classification of Diseases (ICD-10) codes. Included patients had undergone intramedullary nailing for midshaft fractures of the tibia between 2015 and 2020 and subsequently underwent revision surgery due to nonunion. The primary outcome measured in this study was the rate of nonunion following intramedullary nailing for the different types of tibial shaft fractures (closed, Type I/II open, Type III open). For each fracture subtype, the study compared nonunion rates between those who received enoxaparin in the postoperative period and those who did not receive enoxaparin at any time during the first 6 weeks postoperatively. Factors such as the timing and duration of enoxaparin therapy and demographic variables were also considered. The study included 16,986 patients, average age was 49.2 years (SD 17.3); 43.1% were female. Five hundred four patients required revision surgery for nonunion (3.4%). Among patients who did not receive enoxaparin, the nonunion rates were 1.6%, 3.9%, and 6.9% for closed, Type I/II open, and Type III open fractures, respectively. For patients who received enoxaparin within the first 2 weeks, the nonunion rates were 2.6%, 4.7%, and 7.9% for closed (RR = 1.67, P < 0.0001), Type I/II open (RR = 1.21, P < 0.0001), and Type III open (RR = 1.17, P = 0.355) fractures, respectively. Logistic regression confirmed enoxaparin was independently associated with nonunion (odds ratios [OR] = 1.75, P = 0.0013 for closed fractures; OR = 1.51, P = 0.034 for Type I/II open fractures). Tobacco use was also a contributing factor (OR = 2.43, P < 0.0001 for closed fractures; OR = 2.00, P < 0.0001 for Type I/II open fractures; OR = 2.04, P = 0.0008 for Type III open fractures). The postoperative use of enoxaparin was associated with an elevated risk of nonunion in patients treated with intramedullary nailing for fractures of the tibial shaft. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Salvage of a comminuted proximal tibial polymicrobial infected non-union with antibiotic loaded bio-composite and intramedullary nailing: a case report

Background. Management of open proximal metaphyseal fractures poses a significant challenge and is fraught with complications. These injuries are severe, often accompanied by extensive soft tissue and vascular damage, leading to high risks of infection and long-term disability. Case presentation. A 72-year-old male was severely injured in a road traffic accident. Plain X-rays and CT angiogram identified a comminuted proximal tibial fracture with transection of the popliteal artery and vein. Initial emergency treatment included fasciotomies, external fixation, and vascular primary repair. On the 12th day of admission, the patient underwent open reduction and internal fixation (ORIF) with dual plate fixation using a two incision technique. A plastic surgeon performed skin grafting, harvested from the patient’s thigh, to allow closure of his fasciotomy wounds immediately following ORIF. Four weeks post-operatively, the patient developed a wound breakdown over the lateral fasciotomy site, exposing the metal plates with a small defect developing on the medial fasciotomy wound in tandem. The patient’s course was further complicated by persistent polymicrobial infections. Over 6 months of antibiotic regimes, operative intervention was ultimately required. All of the infected metal implants were removed, the non-union sites were aggressively debrided. The tibial canal was reamed to prepare for a tibial nailing. An antibiotic loaded bio-composite was then inserted through the non-union sites into the canal followed by an intramedullary nail. A blocking screw was used to address the procurvatum deformity in the sagittal plane. The patient currently shows signs of recovery, mobilizing over short distances, weight-bearing with assistive aids and with healing wounds and early signs of callus formation on recent CT scans and plain X-rays. Conclusions. The management of complex tibial fractures with vascular involvement demands an aggressive multidisciplinary approach and continuous adaptability in treatment plans to address the evolving challenges of such severe injuries. This case exemplifies the utility of injectable antibiotic-loaded bio-composites in a limb-salvage setting and their ability to provide high doses of local antibiotics to an infection site which, in conjunction with appropriate stable fixation and systemic antibiotics, can aid in eradicating and treating fracture-related infections.

Assessment of functional and radiological outcomes of suprapatellar and infrapatellar approaches of tibial nailing in patients with tibial shaft fracture: A randomized control study

BackgroundThe study aimed to assess functional and radiological outcomes of the suprapatellar approach (SPA) and infrapatellar approaches (IPA) of tibial nailing in patients with closed tibia shaft fractures. MethodAfter Institutional Ethical Committee (IEC) and Clinical Trials Registry- India (CTRI) approval, patients with Orthopaedic Trauma Association (OTA) fracture type 42 were enrolled from August 2021 and August 2022 at a level I trauma centre and randomized to SPA and IPA with informed consent. Demographics, American Society of Anaesthesiologists (ASA) physical grading, intraoperative fluoroscopy time, operative duration, bleeding, postoperative radiographic alignment, and union were compared among both approaches. Functional parameters like Lysholm knee score, Anterior knee pain (AKP), Visual Analog Scale (VAS) Score upon kneeling, Knee Injury and Osteoarthritis outcome score (KOOS), KOOS Patellofemoral score (KOOS PF), EuroQol (EQ5D5L), Forgotten joint score (FJS), Range of motion (ROM) of knee and any complications were assessed at 3,6 and 12 months postoperatively. ResultsPer protocol analysis of 50 patients (25 SPA, 25 IPA) done at the end of the study. SPA group had significantly lesser fluoroscopy time (91.28 ± 12.40s vs. 105.36 ± 9.23s, p < 0.001) and operative duration (mins) (123.80 ± 24.25 vs. 130.00 ± 18.20, p < 0.001) than IPA. No significant differences were noted in Lysholm knee score at three months (p = 0.094), six months (p = 0.406), and 12 months (p = 0.071). The SPA group showed significantly lower VAS Score upon kneeling at six months (p < 0.0001). Similarly, KOOS (p < 0.001), KOOS PF (p = 0.01), and EQ 5D5L (p = 0.03) were significantly better in the SPA group at six months postoperatively. Lower Coronal translation was found in SPA [0 (0–1.8) vs. 1.4 (0.9–1.8), p = 0.010]. Whereas, IPA had higher range of flexion at 3 months [130.0 (129.0–135.0) vs 123.1 (120.0–130.5), p = 0.047]. However, no significant differences were noted in blood loss, AKP, FJS, EQ-VAS, coronal angulation, sagittal malalignment, time to union, return to work and postoperative complications among the groups. ConclusionSPA has lesser surgery time, more straightforward anatomic fracture reduction, better fracture alignment, lesser radiation exposure for both patients and surgeons, quicker recovery time, and promotes early kneeling activities with similar long-term functional outcomes and union rates, and can be considered in routine clinical practice than conventional IPA.

Mechanical comparison of straight and pre-bent interlocking nails used for the stabilization of a tibial gap fracture model.

To compare the mechanical behavior of straight (STRT) and pre-bent (BENT) I-Loc angle-stable interlocking nails (AS-ILN) used for stabilization of canine mid-diaphyseal tibial fractures. In vitro experimental study. Tibial gap fracture models (n = 5/group). Tibial models simulating a comminuted mid-diaphyseal fracture were stabilized with either a STRT or BENT I-Loc AS-ILN. Bent nails were contoured to match the 10° tibial recurvatum of a mid-size dog. Constructs were subjected to cyclic eccentric compressive loads followed by ramp load until failure. Construct compliance, maximum compressive load and resistive torque, yield load and angular deformation at 450 N were statistically compared using t-tests (p < .05). Failure modes were described. Compliance was 45% lower in BENT than STRT groups (p < .0001). Constructs in the BENT group sustained ~20% and 34% greater maximum and yield loads, respectively, than STRT constructs. Maximum resistive torques were similar between groups (p = .16). At 450 N, sagittal plane angular deformation increased from 0° to 4° in procurvatum (STRT group) and decreased from 10° to 8° in recurvatum (BENT group-p < .0001). Construct yield failure occurred at the nail isthmus in both groups. These results demonstrated that, in a tibial gap fracture model, pre-bending I-Loc AS-ILNs provided mechanical advantages by increasing their ability to resist bending resulting from eccentric compressive loads. Pre-bending may reduce the occurrence of tibial nail yield failure. Surgeons should therefore consider pre-bending tibial I-Loc nails to match the bone anatomical recurvatum prior to implantation.

THE USE OF A TIBIA REDUCTION DEVICE IN THE TREATMENT OF FRACTURES UNDERGOING TIBIAL NAILING AT A DISTRICT GENERAL HOSPITAL: A PARALLEL CASE SERIES

Malalignment is a common complication following tibial surgery, occurring in 10% of fractures. This is associated with prolonged healing time and non-union. It occurs due to inability to maintain a satisfactory reduction. A reduction device, such as the Staffordshire Orthopaedic Reduction Machine (STORM), permits the surgeon to manipulate the fracture and hold it reduced.A retrospective parallel case series was undertaken of all patients undergoing tibial nails over a six-year period from 2014 to 2021. Patient demographics were obtained from medical records. Operative times obtained from the theatre IT system and included the time patient entered theatre and surgical start and finish times for each case.Anteroposterior and lateral long leg post-operative radiographs were reviewed. Angulation was measured in both coronal and sagittal planes, by two separate orthopaedic surgeons. A reduction was classified to be ‘mal-aligned’ if the angle measured was greater than 5 degrees. One tailed unpaired t-test was used to compare alignment in each plane. Bony union was assessed on subsequent radiographs and was determined according to the Radiographic Union Score for Tibial Fractures31 patients underwent tibial nail during the time period. 8 patients were lost to follow up and were excluded. Of the remaining 23 patients, the STORM device was utilised in 11.The overall mean alignment was acceptable across all groups at 2.17° in the coronal plane and 2.56° in the saggital plane. Analysing each group individually demonstrated an improved alignment when STORM was utilised: 1.7° (1°–3°) vs 2.54° (0°–5°) for the coronal plane and 1.6° (0°–3°) vs 3.31° (0°–9°) in the saggital plane. This difference was significant in saggital alignment (p=0.03) and showed a positive trend in coronal alignment, although was not significant (p=0.08)The time in theatre was shorter in the control group with a mean of 113 minutes (65 to 219) in comparison to STORM with a mean of 140 minutes (105 to 180), an increased theatre time of 27 minutes (p=0.04).This study demonstrates that STORM can be used in the surgical treatment of tibial fractures resulting in improved fracture alignment with a modest increase in theatre time.

A Prospective Study on Tibial Shaft Fractures Treated with Suprapatellar Approach.

Tibial diaphysis represents the primary location for tibial fractures, accounting for 80% of such cases, often accompanied by fibular fractures. In terms of surgical management, the recommended technique for addressing both displaced and undisplaced tibial shaft fractures in adults is intramedullary nail fixation. Additionally, there is a growing consideration for suprapatellar nailing, which involves performing the procedure with the knee in a semi-extended position, as a potentially safe and efficacious alternative. To evaluate the clinical and functional union amongst tibial shaft fracture cases, managed by nailing in the suprapatellar approach, and to study the complications associated with it. Our study with prospective observational design was conducted for 18 months on 30 patients with tibial shaft fractures. Following comprehensive laboratory assessments and confirmation of surgical fitness, the patients underwent surgical intervention through a specialised suprapatellar approach employing expert tibial nailing. The mean age of the subjects was 42.83 ± 11.47 years, and the majority were males (70.0%). Notably, there was a statistically significant reduction in Visual Analogue Scale scores and a concurrent increase in Lysholm Knee Scoring Scale scores during the follow-up period, indicating substantial enhancements in both clinical and functional outcomes. Delayed union was the complication observed in three individuals. We found that the younger the age of the subjects, the earlier the surgery after an injury, the better the functional outcome. Expert tibial nailing with a suprapatellar approach was successful in yielding clinical and functional union amongst the subjects with tibial shaft fractures. In addition, delayed union was the complication observed in the approach, which was evident in a few cases.

Superior accuracy in knee double level osteotomy using a novel hybrid fixation technique compared to conventional double plating.

This study aimed to compare two different double-level knee osteotomy (DLO) fixation techniques. The primary outcome reported the radiological coronal plane correction and its accuracy. The secondary outcomes reported the correction outliers, the clinical outcomes, the 5-year postoperative satisfaction and the complications. A retrospective review of a single surgeon osteotomy database identified 52 cases of DLO between 2011 and 2019, of which 24 cases met the inclusion criteria. Patients were categorised into two groups: the nail-plate (NP) group fixed with a magnetic extendable intramedullary tibial nail and femoral conventional plate, and the double-plate (DP) group fixed with conventional plates (tibia and femur). Radiographic parameters were recorded, including the mechanical femorotibial angle (mFTA), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle (mLDFA), joint line convergence angle (JLCA) and weight-bearing line ratio (Mikulicz %). Surgical accuracy was calculated as the difference between the achieved and the planned correction. Outliers were defined as those with a greater than 10% difference from the planned correction. Simple knee value scores and visual analogue scale for pain were recorded preoperatively and postoperatively at 2 and 5 years. Five-year patient satisfaction was recorded. A total of 24 patients were included: the NP group (n = 12) and the DP group (n = 12). Significant coronal plane corrections were achieved in the NP group for the mean mFTA (preoperative 167.9° ± 3.4° to postoperative 182.1° ± 1.4°), the mean MPTA (preoperative 83.5° ± 2.9° to postoperative 91.3° ± 2.8°) and the mean mLDFA (preoperative 89.8° ± 3.4° to postoperative 85.9° ± 4.4°). Similarly, significant coronal plane corrections were achieved in the DP group for the mean mFTA (preoperative 168.6° ± 4.4° to postoperative 182.2° ± 2°), the mean MPTA (preoperative 84.2° ± 2° to postoperative 88.3° ± 4.1°) and the mean mLDFA (preoperative 90.7° ± 2.9° to postoperative 83.9° ± 1.7°) (all p < 0.05). The mean correction accuracy was higher for the NP versus DP group at 3.4 ± 3.4% versus 7.1 ± 3.9% (intergroup p < 0.05). There were no outliers in the NP group versus two outliers (overcorrected) (16.7%) in the DP group. Significant clinical improvement was reported in both groups at 2 and 5 years postoperatively (all p < 0.05). Superior correction accuracy and no outliers were achieved in hybrid fixation double-level knee osteotomy compared to the conventional double-plating technique. The magnetic extendable nail offers the advantage of fine-tuning the correction postoperatively and could be a potential research template for future designs of postoperative correction implants. Level III, retrospective cohort study.

Exploring Knee Flexion Techniques in Tibial Nailing: A Comparative Study of Two Different Methods Knee Flexion Techniques in Tibial Nailing.

Tibial fractures, particularly diaphyseal fractures, are common and can result in prolonged non-weight-bearing periods, especially in older adults. Intramedullary nailing has become the standard treatment, offering early weight-bearing and improved functional outcomes. This study aims to compare the efficacy and safety of two knee flexion methods - Method A (using an adjustable triangular frame) and Method B (Seyhan method) - in tibial nailing procedures. A prospective randomized controlled trial was conducted with 90 adult patients aged 18-70 requiring intramedullary nailing for isolated closed tibial fractures. Method A utilized an adjustable triangular frame, allowing various degrees of knee flexion. In Method B (Seyhan method), knee flexion was achieved by leg sloping on the operation table with a cushion pillow under the distal thigh. In terms of complication rates, a key finding was a significantly higher incidence of edema in Method B compared to Method A. The results indicated minor differences in satisfaction levels, with a slightly higher percentage of 'Well Satisfied' and a higher dissatisfaction rate in Method B. However, these variations in surgeon satisfaction did not reach statistical significance. 1. The Seyhan method and the adjustable triangular frame were compared in our study, with the latter showing advantages in terms of ease of use and reduced complications. 2. While complications like knee pain were observed in some cases, the triangular frame showed superior results in surgical efficiency and patient outcomes. 3. Further research is needed to confirm these findings and explore specific scenarios where each method may excel.

A case control study to compare the effect of dynamisation of tibia nail in union of tibia shaft fracture versus non-dynamisation

A case control study to compare the effect of dynamisation of tibia nail in union of tibia shaft fracture versus non-dynamisation

DISTAL TIBIA FRACTURE MANAGED BY EXPERT TIBIA NAIL: POSTOPERATIVE COMPLICATIONS

Distal tibial fractures present a significant challenge in orthopaedic surgery due to their complex nature and the risk of complications. Expert tibia nails (ETN) have emerged as a potential solution for improving functional outcomes and reducing complications in these fractures. Objective: To assess the complications and functional consequences of using expert tibia nails (ETN) in patients with distal tibial fractures. Methods: This prospective study included thirty patients with distal tibial fractures treated using expert tibia nails (ETN). The study was conducted from January 2023 to June 2023 at department of orthopedic surgery, Hayatabad Medical Complex, Peshawar. Functional outcomes were assessed using a standardised scoring system, and complications were monitored. Statistical analysis included descriptive statistics to summarise the data. Results: The mean age of the patients was 44.80 ± 9.50 years. The functional outcome was excellent in 21 patients (70%), good in 7 patients (23.3%), and fair in 2 patients (6.7%). Complications observed included malunion in 2 patients (6.7%), nonunion in 1 patient (3.3%), and infection in 3 patients (10%). Conclusion: The use of expert tibia nails (ETN) in treating distal tibial fractures resulted in excellent to good functional outcomes in most patients. The rates of complications such as malunion, nonunion, and infection were relatively low, indicating that ETN is a reliable method for managing distal tibial fractures.

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

IntroductionThe 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 methodsThis 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. ResultsFive 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. DiscussionDTN 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. ConclusionsDTN 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.

The study of outcome in fractures of proximal third of tibia in adults treated by expert tibia nail

This study aims to evaluate the clinical, functional outcome and complications of fracture proximal third of tibia treated with expert tibia nail in terms of radiological union, functional outcomes by short form -36 (SF-36) score, Johner and Wruhs criteria, visual analogue score and patient satisfaction score. Twenty-five patients with fracture proximal third of tibia treated with expert tibia nail in SNMC and HSK hospital and research centre, Bagalkot were enrolled in this study. The radiological union was assessed by plain radiograph and functional outcome by SF-36 score, Johner and Wruhs criteria, visual analogue score and patient satisfaction score. The radiological union was achieved in all the patients between 14 to 26 weeks duration (mean of 19.6±2.82 weeks). The mean SF-36 score was 84.9±4.06 and the mean visual analogue score was 2±1.78 at the 22nd week of follow-up. Results based on Johner and Wruhs criteria, 17 patients had excellent, 6 had good, 1 had fair and 1 had poor results. The average patient satisfaction score was 8.88 out of 10. There were 8 cases of post-operative knee pain, 5 cases of infection, 2 cases of malunion, 1 case of shortening and 1 case of the delayed union in our study. Intramedullary fixation with expert tibia nail for fracture proximal third tibia is a safe and less invasive technique. The radiological union was achieved in all the cases. This technique ensures excellent functional outcomes and a low incidence of complications.

Circular frame versus reamed intramedullary tibial nail in the treatment of grade III open tibial diaphyseal fractures.

Grade III open tibial diaphyseal fractures are challenging to treat and controversy exists on whether to treat them with an intramedullary nail (IMN) or a circular frame (CF). This study aims to compare outcomes for intramedullary nail and circular frame in the treatment of open tibial diaphyseal fractures. Retrospective study at a major trauma center of all patients admitted with a grade III open tibial diaphyseal fracture between January 2016 and January 2022. The primary outcome measures were major complications: non-union, malunion, refracture, DBI and amputation. Secondary outcome measures were time to union and reoperation rates. Fifty-five patients were included in the study, 32 patients in CF group and 23 patients in IMN group. There were no significant differences in the baseline demographics of patients in both groups. Major complications were recorded in 13 limbs (54%) in IMN group and in 18 limbs (56%) in CF group which were not statistically significant (p = 0.797). Deep bone infection rates were noted in 4 (12.5%) in the CF group, compared to 1 (4%) in IMN group; however, the result was not statistically significant (p = 0.240). Amputation rates as a result of infected non-unions were seen in 1 limb (4%) in IMN group and 2 limbs (6%) in CF group (p = 0.99). Median time to union was significantly shorter in IMN group at 30weeks compared to 30weeks for CF group (p = 0.04). IMN should be the treatment of choice in the treatment of grade III open tibial diaphyseal fracture, but CF should be considered for delayed treatment and in patients with bone loss.

A retrospective investigation on clinical and radiographic outcomes of distal tibial fractures after intramedullary nailing using the lateral parapatellar extra-articular approach.

According to reports, the modified extra-articular parapatellar approach allows the performance of tibial nailing in the semi-extended position without the concern of joint violation. However, there remains no special study that has provided a detailed assessment of the benefits and risks of this approach for treating distal tibial fractures (DTFs). The aim of this retrospective study was to investigate the clinical and radiological outcomes of patients with DTFs after intramedullary nailing using a lateral parapatellar extra-articular (LPE) approach in comparison to using the suprapatellar (SP) and transpatellar (TP) approaches. Data were collected from 99 patients with a minimum follow-up period of 12 months. Comparisons were conducted between the groups regarding the number of intraoperative fluoroscopies, complications, knee pain, knee range of motion (ROM), the Lysholm Knee Scale (LKS), the Olerud-Molander Ankle Score (OMAS) and radiological findings. The demographic characteristics were comparable between the groups. Fewer intraoperative fluoroscopies were performed in the LPE (27.47 ± 4.98) and SP (26.03 ± 5.12) groups than in the TP group (30.20 ± 7.42; P<0.001). When compared with the other two approaches, the LPE approach was associated with less knee pain (P<0.001) and better knee ROM (P<0.001) at one week postoperative. No significant intergroup differences were detected in the incidence of complications, LKS scores (P = 0.687) and OMAS (P = 0.926). Radiological findings demonstrated that postoperative tibial alignment (P = 0.853), the time of bony union and rate of non-union were similar between the groups. The LPE approach can serve as a safe and effective option for tibial nailing, as it offers favourable outcomes in knee pain relief and knee ROM in the early postoperative period and is equivalent to the other two approaches in terms of the incidence of complications, fracture healing, functional recovery and postoperative alignment for patients with DTFs.

Infrapatellar branch of the saphenous nerve lesion following tibial nailing: it is possible to avoid it?

Iatrogenic injury to the infrapatellar branches of saphenous nerve is a common complication following tibial nailing. This lesion seems to be directly related to the surgical approach adopted for nail insertion. The aim of the present study was to systematically review the current literature in order to assess the eventual superiority of one surgical approach for tibial nailing over the others in limiting the neurological impairment related to infrapatellar branch injury. The available literature was systematically screened searching papers dealing with iatrogenic injury to the infrapatellar branch of saphenous nerve after intramedullary tibial nailing. The terms "Saphenous" and "Infrapatellar branch" were used in combination with "intramedullary nailing" and "tibial fractures", supplying no limits regarding the publication year. Only publications in English were considered. Case reports, technical notes, instructional course, literature reviews, biomechanical and/ or in vitro studies were all excluded. Coleman methodological score was performed in all the retained articles. Four articles matched the inclusion criteria. There were one original article and three retrospective study. Hypoesthesia and a larger extension of the area of sensory-loss were more frequently observed after vertical incision approach in three out of four articles. A trend towards a lower rate of iatrogenic nerve damage using a transverse incision was found in the remaining one, without any statistical significance. In order to avoid infrapatellar nerve lesion, horizontal or oblique incisions or percutaneous approaches should be favored, although in some cases a longitudinal incision is required. Limited-extension incisions could minimize the risk and the incidence of this complication.

Intramedullary tibial nailing: percutaneous suprapatellar approach with the knee in semi-extended position and the EstreMO nail. The Italian contribution

Intramedullary tibial nailing: percutaneous suprapatellar approach with the knee in semi-extended position and the EstreMO nail. The Italian contribution

Proximal Tibia Fracture Through Suture Augmentation Sites Following ACL/MCL Repairs: A Case Report.

A 35-year-old man sustained a proximal tibia fracture from a low-energy mechanism 1 year after anterior cruciate and medial collateral ligament repairs with suture augmentation (SA). The fracture propagated through both tibial SA anchor sites. Following intramedullary tibial nailing, he returned to his prior level of function. While complications of SA for ligamentous procedures are rare, these techniques are being implemented more frequently and the full complication profile is yet to be determined. Our report documents a new complication and potential risk factors that surgeons should consider when performing SA for multiligament knee surgery in active individuals.

Prevalence of Rotational Malalignment After Infrapatellar Versus Suprapatellar Intramedullary Nailing of Tibial Shaft Fractures.

Up to 30% of patients with a tibial shaft fracture sustain iatrogenic rotational malalignment (RM) after infrapatellar (IP) nailing. Although IP nailing remains the management of choice for most patients, suprapatellar (SP) nailing has been gaining popularity. It is currently unknown whether SP nailing can provide superior outcomes with regard to tibial RM. The aim of this study was to compare the differences in the prevalence of RM following IP versus SP nailing. This retrospective study included 253 patients with a unilateral, closed tibial shaft fracture treated with either an IP or SP approach between January 2009 and April 2023 in a Level-I trauma center. All patients underwent a postoperative, protocolized, bilateral computed tomography (CT) scan for RM assessment. RM was observed in 30% and 33% of patients treated with IP and SP nailing, respectively. These results indicate no significant difference (p = 0.639) in the prevalence of RM between approaches. Furthermore, there were no significant differences in the distribution (p = 0.553) and direction of RM (p = 0.771) between the 2 approaches. With the IP and SP approaches, nailing of left-sided tibial shaft fractures resulted in predominantly internal RM (85% and 73%, respectively), while nailing of right-sided tibial shaft fractures resulted in predominantly external RM (90% and 80%, respectively). The intraobserver reliability for the CT measurements was 0.95. The prevalence of RM was not influenced by the entry point of tibial nailing (i.e., IP versus SP). Hence, the choice of surgical approach should rely on factors other than the risk of RM. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.