Fracture-isthmus diameter ratio predicts delayed union in tibial nailing.

To compare the short-term outcomes and complications of the poller screw (PS) and the poller K-wire (PW) in distal tibia nailing. In the present study, a retrospective analysis was performed on prospectively collected data, 43 cases were included in the study. 16 patients were included in the PS group and 27 patients in the PW group. Demographic data, fracture union times, RUST scores, alignment in the coronal and sagittal planes, associated fibula fractures and fixation, malunion, and complications were compared. A subgroup analysis was performed according to fibula fixation and the number of distal locking screws. There was no significant difference between PS and PW groups in respect to age, gender, trauma etiology, fracture-joint distance and AO classification of fractures. In the PS group, the operation time and final coronal angulation were significantly higher (operation time: 81.5 ± 15.27 minutes and 72.22 ± 11.79 minutes, respectively, p = 0.031; coronal angulation: 3.12° ± 3.2° and 1.24° ± 1.76°, respectively, p = 0.044). No statistically significant difference was found in terms of fracture healing time and RUST scores. Non-union was observed in one patient in the PS group. There was no significant difference in fracture healing times and RUST scores when subgroup analysis was performed according to fibula fixation and distal locking screw numbers. The PW technique offers significant advantages in terms of surgical efficiency and reduction quality in the coronal plane. Although the risk of wire displacement remains a disadvantage that must be minimised with careful technique, these advantages make PW a preferable alternative to PS for assisting reduction in distal tibial nailing, where PS has disadvantages such as longer operating times and less optimal alignment control. The use of PW instead of PS has no negative effect on fracture union time and also improves alignment and decreases the operative time.

Introduction:Tibial shaft fractures are common pediatric injuries. Rigid intramedullary nails (RIMN) are widely used for the fixation of complex tibial shaft fractures in skeletally mature individuals, but their safety is debated in patients with open physes. There has been growing support for the use of RIMN fixation in pediatric patients due to the stability and rapid return to weight-bearing activities they offer. In this study, we evaluate the utility and safety of suprapatellar RIMN fixation in skeletally immature children with tibial shaft fractures.Materials and Methods:This retrospective case series includes seven skeletally immature patients treated with suprapatellar RIMN fixation of tibial shaft fractures at a single level one trauma center between May 1, 2009, and May 1, 2024. The primary outcome of interest was clinical signs of iatrogenic growth arrest. Secondary outcomes of interest included post-operative complications and time to full weight bearing (FWB), union, and sport.Results:The mean age at the time of operation was 13.7 years (range: 12–15) and the mean follow-up time was 14.21 months (range: 6–26.5). We observed no clinical evidence of iatrogenic growth arrest or limb deformity post-operatively. The mean time to union was 24.17 weeks. On average, patients returned to FWB and full activity/sport at 10.33 and 22.67 weeks, respectively. The majority of patients (n = 5) did not require hardware removal with the exception of one patient who developed a deep tissue infection and another with delayed union of an associated fibula fracture.Conclusion:In a series of seven skeletally immature children, suprapatellar RIMN fixation of tibial shaft fractures was not associated with iatrogenic growth arrest. Benefits of this fixation technique include an expedited return to weight-bearing activity and sport.

Suprapatellar versus infrapatellar tibial nailing: the ongoing debate.

Introduction with Objective: Tibial shaft fractures are the most prevalent type of tibia fracture. Intramedullary nailing is the standard procedure for surgical treatment of displaced tibial shaft fractures. Tibial nail insertion with suprapatellar approach with the knee in semi extended position which has advantage over infrapatellar approach. The aim of this study is to compare the surgical and clinical outcome of suprapatellar and infrapatellar approach for the tibial intramedullary nailing in patient with tibial shaft fractures. Methods: This Prospective Study was carried out among 48 patients attending at the department of Orthopedics Surgery at Chittagong Medical College Hospital; Chittagong for the treatment tibial fracture within the defined period from May 2022 to April 2023. Total 4 patients were dropped out in the middle of follow up. So follow up was done among 44 patients. All the data were compiled and sorted properly and the quantitative data was analyzed statistically by using Statistical Package for Social Science. Results: Twenty two patients in each group completed the study per protocol and included in the analysis. Both groups are comparable in terms of their age, fracture type and fracture location (P>0.05) .The average time of union was 3.52±0.898 months and 3.36±0.790 months respectively in suprapatellar and infrapatellar approach group (P=0.535). The average duration of operation was 90.04±8.035 and 76.46±9.060 minutes respectively in suprapatellar and infrapatellar approach group (P<0.001). Mean ± SD fsluroscopy time in suprapatellar approach was 115.58 ± 8.387 seconds and in infrapatellar approach was 105.38±9.102 (P<0.001). There was no significant difference among the two groups of nailing according P Value regarding complication like malalignment. Average ROM in suprapatellar approach group was 130.91±1.5 and in infrapatellar approach group was 125.38±1.88 (P<0.001). Suprapatellar approach shows significantly better outcome by mean Lysholm Knee score in comparison to infrapatellar approach according (P Value). The proportion of patients achieved excellent functional outcome was 18(81.8%) and 17(77.3%) in suprapatellar and infrapatellar approach group (P=0.892). Conclusion: It can be concluded that suprapatellar approach produced better functional outcome than infrapatellar approach in the treatment of tibial shaft fracture when considering mean lysholm knee score, range of motion and rate of malalignment in this present clinical trial. Medicine Today 2026, Vol.38 (1): 56-59

This study presents an in-silico assessment of RF-induced heating of orthopedic implants during various stages of bone fracture healing, namely surgery, scar, and healed phases, under 1.5 T and 3.0 T MRI. Computational human models Duke, Ella, and Fats were used to develop the stages of bone fracture healing. These models reflect clinically relevant conditions and also include assessment of the surgery model with the presence of tissue adhesive and its leakage. Two types of orthopedic implants are analyzed: (a) a tibial nail system embedded within bone, and (b) a reverse shoulder arthroplasty (RSA) implant located partially in bone and muscle. Results demonstrate variations in RF-induced heating across stages of bone fracture healing and anatomical models, indicating that localized tissue properties, location of the implantation as well as the presence of tissue adhesive significantly influence RF-induced heating. The findings highlight the importance of (a) integrating clinically relevant in silico models to evaluate the safety of patients undergoing MRI scans which are not included in the current testing standards for passive implantable medical devices, and (b) accurate labeling of orthopedic implants for testing in an MRI environment.

Tibial shaft fractures are common in the pediatric population. As patients approach skeletal maturity, rigid intramedullary nailing of these fractures is a potentially advantageous option, allowing rigid fixation and earlier mobilization and weight-bearing. However, potential injury to the open proximal tibial physis in patients with remaining growth remains a concern. This study sought to determine the rate of growth disturbance following rigid, transphyseal tibial nailing of tibial shaft fractures in patients with open physes. This was a retrospective study of skeletally immature patients who were treated with transphyseal nailing of a tibial shaft fracture. Included patients had at least 1 year of growth remaining, as determined by the Modified Fels Skeletal Maturity System, and at least 1 year of follow-up. Growth disturbance was determined by a change in posterior tibial slope or medial proximal tibial angle on radiographs obtained at the time of injury as compared with radiographs at final follow-up. A total of 20 patients were included in the study. The mean chronological age of the cohort was 14.5 years (SD=1.47, range: 12 to 17y) at the time of injury. The mean skeletal age at the time of injury in female patients was 12.6 years (SD=0.4, range: 12.0 to 13.0) and in males, 14.4 years (SD=0.7, range: 12.5 to 15.0). The cohort had a mean of 1.51 years of growth remaining (SD=0.6, range: 1 to 3.5y). There was no significant change in the mean posterior tibial slope or medial proximal tibial angle between injury and final radiographs ( P =0.467, 0.906, respectively). Two patients developed a decrease in posterior tibial slope angle (flattening of slope) of greater than 3 degrees (3.9 and 6.7 degrees). Rigid transphyseal nailing of pediatric tibial shaft fractures in patients with open physes who are approaching maturity remains a safe treatment option; however, when more than 1 year of growth remains, surgeons must carefully monitor patients for the development of angular deformity at the knee.

Infection is one of the major complications associated with intramedullary nailing. Aim of this study is to analyze the outcome of infection after fixation of tibia and femur with intramedullary nailing and to compare the outcome in patients treated with nail retention versus removal. This is a retrospective cohort study including consecutive adult patients treated at our institution between 01/2015 and 03/2022 for infection involving the intramedullary nail used for fixation of femur or tibia fractures. Characteristics of infection and outcome data were evaluated by actively contacting the patients with a standardized questionnaire. Uniform predetermined definitions were used. The probability of infection-free survival was estimated using the Kaplan-Meier method and compared between the groups using log-rank test. Fifty-one patients (37 males, 14 females) with infection associated with femur (n = 37) or tibia (n = 14) nail were included. The pathogen was identified in 45 (88 %) episodes, including 30 monomicrobial and 15 polymicrobial infections. The predominant pathogens in monomicrobial infections were coagulase-negative staphylococci (n = 11) and in polymicrobial infections gram-negative bacteria. The intramedullary nail was removed in 35 (69 %) patients and retained in 16 (31 %) patients. At follow-up (median follow-up 28 months; IQR 21-38 months), 19 of 31 (61 %) evaluable patients were infection-free. In patients with nail removal, 14 of 22 (64 %) were infection-free, whereas those with nail retention, 5 of 9 (56 %) were infection free. The fact that patients in the nail retention group were of higher age, experienced earlier infection after surgery, and were mainly caused by high virulent pathogens suggest a potential selection bias. Nevertheless, it appears that certain infections may be treated successfully with nail retention, reducing the number of interventions for the patient, and increasing cost effectiveness. Overall cure of infected intramedullary nails was 61 %. No significant difference in the infection eradication of infected intramedullary nails were observed, irrespective of the time of occurrence after nail implantation. These results should be confirmed in a larger prospective cohort.

Background Management of extra-articular distal tibia fractures associated with supra-syndesmotic fibula fractures remains controversial, particularly regarding the need for fibular fixation. With the advent of the Expert Tibial Nail System (ETNS), which provides multidirectional distal locking, adequate stability may be achieved without fibular fixation, potentially reducing surgical morbidity. Objective To compare clinical, radiological, intra-operative parameters, and complication rates between isolated ETNS fixation and conventional tibial intramedullary (IM) nailing with fibular plating in extra-articular distal tibia and fibula fractures. Materials and methods A hybrid (prospective and retrospective) comparative study was conducted from April 2023 to March 2025, including 120 patients aged 18-60 years with extra-articular distal tibia fractures (4-10 cm from the tibial plafond) and associated supra-syndesmotic fibula fractures. Sixty patients were treated with isolated ETNS fixation, and sixty underwent conventional tibial nailing with fibular plating. Intra-operative parameters (duration of surgery, blood loss, and radiation exposure), time to union, Olerud-Molander ankle score, deformity, and complications were analyzed. Statistical analysis was performed using Student's t-test and the chi-square test, with significance set at p < 0.05. Results The mean duration of follow-up of 14.2 months. The ETNS group demonstrated significantly shorter operative time (32.9 vs. 63.86 minutes), lower blood loss (15.53 vs. 48.91 mL), and reduced radiation exposure (22.68 vs. 33.55 C-arm shots) (p < 0.05). Mean union time was significantly earlier in the ETNS group (18.1 vs. 22.5 weeks, p < 0.001). Functional outcome assessed by the Olerud-Molander ankle score was superior in the ETNS group (96 vs. 90.66, p < 0.001). Overall complications were fewer with ETNS (23.33%) compared with tibial nailing with fibular plating (43.33%), with higher rates of infection, ankle stiffness, and non-union observed in the fibular fixation group. Conclusion Isolated ETNS fixation for extra-articular distal tibia fractures with associated supra-syndesmotic fibula fractures provides superior clinical and radiological outcomes, earlier union, reduced operative morbidity, and fewer complications compared with conventional tibial nailing with fibular plating. Routine fixation of the fibula may not be necessary when stable multidirectional tibial fixation is achieved with ETNS.

Introduction: Although intramedullary nailing is the treatment of choice for the management of tibial diaphyseal fractures, they are infrequently used in the very proximal and distal third fractures due to their technical limitations. Hence, the conventional nail has been modified to Multidirectional Tibia Nail, which improves the stability of the fixation and reduces secondary malalignment. We aimed to assess the functional outcomes of extra-articular proximal and distal third tibia fractures treated with multidirectional tibia nailing in terms union outcomes and associated complications. Materials and Methods: In this study, we assessed the time of union, functional outcomes, radiological outcomes, and associated complications, in 30 patients with extra-articular tibial fractures who were treated using Multidirectional Tibia Nail. Results: The mean time of union of fracture was 20.97±4.01weeks. The radiological union evaluated using the RUST (Radiographic Union Scale in Tibia fractures) had a mean score of 10.77±1.19. The functional outcomes measured using Johner-Wruhs criteria showed 23 excellent, five good, and two fair outcomes. Majority of the patients regained full range of movements of both the knee and ankle joints. The mean duration of the union was higher among open type, distal third, and AO type C fractures. We noted two (6.7%) cases of superficial infections, five delayed unions (17%), and two patients with shortening (6.7%). Four patients (12.1%) required dynamization. Radiologically, 4 cases (13.4%) had primary malalignment, and two (6.7%) had secondary malalignment. Conclusion: We could extend the indications of intramedullary nailing to treat high or low-lying fractures using Multidirectional Tibia Nail. It provides stable internal fixation and has a lower rate of complications.

Background: Tibial shaft fractures are frequently treated with intramedullary nailing; however, malalignment remains a concern, particularly in proximal metaphyseal fractures. The surgical approach influenced the nail entry point; however, the three-dimensional (3D) geometric characteristics of the entry point among different approaches remain unclear. Methods: This single-center retrospective study included 68 patients with acute tibial shaft fractures (AO/OTA type 42) treated with reamed and locked intramedullary nails from January 2014 to June 2024. The surgical techniques employed included lateral parapatellar (LPA, n = 31), infrapatellar (IPA, n = 27), and suprapatellar (SPA, n = 10) approaches. Postoperative computed tomography (CT) data were reconstructed into standardized 3D images. The mediolateral insertion ratio was calculated as the percentage distance from the lateral tibial plateau edge to the nail entry point relative to the plateau’s width in the coronal plane. The shortest distance from the tibial articular surface to the nail (r) was measured in the sagittal plane. The Kruskal–Wallis test and Dunn’s post hoc comparisons were used to analyze group differences. Results: Baseline patient and fracture characteristics did not significantly differ among the groups. The mediolateral insertion ratio significantly differed (p < 0.0001), with a more lateral entry for the LPA (44.0% [43.0–47.0]) than for the IPA (51.0% [49.0–53.0], post hoc p < 0.0001) and SPA (49.0% [47.0–51.3], post hoc p = 0.0034). Further, the sagittal distance r significantly differed (p < 0.0001), with a more distal entry for the LPA (14.8 [12.8–20.1] mm) than for the IPA (9.7 [7.0–11.8] mm, post hoc p < 0.0001) and SPA (10.5 [5.5–12.9] mm, post hoc p = 0.0008). No statistically significant difference was observed between the IPA and SPA. Conclusions: The LPA generates a significantly more lateral and distal tibial nail entry point than the IPA and SPA. No statistically significant differences were detected between the IPA and SPA in either plane. These 3D-CT findings may warrant attention during approach selection and guidewire placement, particularly for fractures extending into the proximal metaphysis.

Radiation exposure in orthopaedic trauma surgery: A systematic review and meta-analysis.

Surgeon self-confidence is a valued trait that may be built over time and can improve surgeon-patient relationships. The authors seek to study how the use of Virtual Reality (VR) impacts the confidence of a naive trainee. Twenty-five first- and second-year medical students were recruited to compare methods of preparation for intramedullary tibial nail insertion. Participants were randomized into groups that used a technique guide, VR simulation, or both. Each completed assessment of confidence and retention before and after preparation. Procedural confidence was significantly higher in the VR and combined groups in three of the four parameters evaluated: confidence with steps, confidence with a compact bone model, and confidence performing the surgery with an attending present. Retention of procedural steps was significantly higher in VR and combined groups. A trainee's confidence and short-term retention of a procedure can be improved through virtual reality simulations. Improved confidence may foster improved autonomy and improve trainee education. (Journal of Surgical Orthopaedic Advances 35(1):041 - 044, 2026).

The aim of this study was to compare the biomechanical properties of a newly designed Tibial Intramedullary Nail-Distal Supportive Bolt Locking Screw (TIN-DSBLS) and medial anatomical plate in distal tibia fracture models using finite element analysis (FEA). Twelve medium-size, fourth-generation composite tibia models were used for testing. Models were divided into two groups as plate and nail group. A standardized osteotomy was made through each model. In the plate group, osteotomized models were fixed with distal tibia medial anatomic plate. Models in nail group were fixed with new design intramedullary nail with distal Bolt screw locking. All bone models were tested by an axial loading test machine to measure the force, maximum force, fracture site displacement and Stiffness. The second step of this study was FEA of the two models. The results of axial loading test results of two groups revealed that for distal tibia fracture, tibia nail which was locked with newly designed bolt screw showed superiority against plate-screw fixation about force (1597.76 ± 85.54 vs. 830.74 ± 146.7 N), maximum force (3617.6 vs. 1512.42 N), fracture site displacement (4.89 ± 1 vs. 7.85 ± 0.5 mm) and stiffness (357.88 ± 52.6 vs. 109.67 ± 13.6 N/mm). In FEA, maximum stress levels in implants were 1.7 time higher in nail group, bones were not exposed to higher levels of stress or deformation as in plate group. Maximum stress levels in bones of the nail group were 2.75 times lower than plate group. Total displacement in the plate group was more than two-fold compared to the nail group. Our study results showed that the TIN-DSBLS provides more load transfer from the nail to the cortex in tibia distal metaphyseal fractures compared to traditional nails. Taken together, it is biomechanically superior to plate-screw fixation in fractures extending up to 2.5 cm proximal to the ankle joint.

The December 2025 Trauma Roundup 360 looks at: Immediate weightbearing: the INWN pragmatic, randomized, multicentre trial; Operative versus nonoperative management of fractures of the humeral diaphysis: the humeral shaft fracture fixation randomized clinical trial; Operative versus nonoperative treatment for non-displaced Lisfranc injuries; Supra-patellar and infra-patellar tibial nailing? A prospective, randomized controlled trial; Preventing heterotopic ossification after acetabular fracture surgery; Built to break? The risk of medial meniscus posterior root tears; Stitch or skip? Closing external fixator pin sites cuts infection risk.

Introduction: Distal third tibial shaft fractures are challenging to manage due to poor soft tissue coverage and high risk of malalignment and delayed healing. Modified interlocking intramedullary nailing offers improved stability and early mobilization compared to conventional methods. Objective: This study aimed to evaluate the clinical, radiological, functional, and structural outcomes of distal third tibial shaft fractures treated with the modified interlocking intramedullary tibial nail. Methods: This prospective observational study was conducted in the Department of Orthopaedic Surgery at the National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh from July 2016 to June 2018. A total of 30 patients aged between 18 and 65 years of both sexes, presenting with distal third tibial shaft fractures (AO classification types 42A1–3 and 42B1–3) were included. Data was analyzed using the Statistical Package for Social Sciences (SPSS), version 22. Results: In this study of 30 patients with distal third tibial shaft fractures treated using a modified interlocking intramedullary tibial nail, the majority achieved radiological union within 16–18 weeks and full weight bearing by 14–16 weeks. Most patients experienced no pain, deformity, or significant motion loss, with 90% showing excellent-to-good functional recovery per the Karlström–Olerud score. Overall, the procedure provided stable fixation, rapid healing, and satisfactory functional and structural outcomes with minimal complications. Conclusion: Treatment of distal third tibial shaft fractures with the modified interlocking intramedullary tibial nail yields excellent clinical, radiological, functional, and structural outcomes with minimal complications. J Rang Med Col. 2025 Sep;10(2): 156-162

Background: Distal third tibial shaft fractures are challenging due to limited soft tissue coverage and poor vascularity. We compared minimally invasive plate osteosynthesis (MIPO) with distal tip-locking intramedullary nailing.Methods: A prospective two-center cohort of 40 adults with extra-articular distal third tibial fractures was allocated to MIPO (n = 20) or intramedullary nailing (IMN) (n = 20). Primary outcomes were time to union and six-month functional results (AOFAS). Secondary outcomes included infections, malalignment, and secondary procedures.Results: Mean age was similar (MIPO 35.22 ± 5.53 years; IMN 35.52 ± 5.90). Sex distribution was as follows: MIPO 15 (75%) men and five (25%) women; IMN 14 (70%) men and six (30%) women. Union was faster with IMN (14 ± 2.5 weeks) than with MIPO (17 ± 4 weeks). AOFAS at six months showed that in the MIPO group, 12 (60%) were excellent, six (30%) were good, and two (10%) were fair. In the IMN group, 14 (70%) were excellent, four (20%) were good, and two (10%) were fair. Superficial infection occurred in four (20%) in the MIPO group versus three (15%) in the IMN group; no infection occurred in 16 (80%) in the MIPO group versus 17 (85%) in the IMN group. Malalignment occurred in one (5%) in the MIPO group versus three (15%) in the IMN group. Secondary procedures in the MIPO group included one (5%) revision and three (15%) debridements, with 16 (80%) requiring none. In the IMN group, two (10%) required dynamization, and 18 (90%) required no additional procedure.Conclusions: For extra-articular distal third tibial fractures, IMN achieved faster union and a higher proportion of excellent AOFAS outcomes, with similar low rates of complications, whereas MIPO showed a lower malalignment rate. Both techniques are viable, with IMN favored when earlier union is prioritized.

BackgroundWith the increasing adoption of the suprapatellar approach for intramedullary tibial nailing in diaphyseal tibial fractures, this study compared intraoperative and postoperative outcomes between infrapatellar nailing (IPN) and suprapatellar nailing (SPN).MethodsA retrospective analysis was conducted on 51 SPN and 58 IPN procedures performed at a single trauma center between October 2018 and June 2023. Operative time, postoperative blood loss, functional outcomes using the Lysholm score, and the incidence of anterior knee pain (AKP) at follow-up were compared.ResultsThere were no significant differences in age or sex between the groups. Mean follow-up was 36.74 ± 18.11 months for SPN and 35.98 ± 15.11 months for IPN. Mean operative time was significantly shorter in the SPN group (79.7 ± 34.0 min) compared to the IPN group (91.9 ± 36.0 min, p < 0.05). The SPN group showed significantly higher Lysholm scores (89.45 ± 9.2 vs. 85.1 ± 10.5, p = 0.017) and a lower incidence of AKP. No significant difference was observed in postoperative blood loss.ConclusionCompared to the IPN approach, SPN for diaphyseal tibial fractures may reduce operative time, decrease the incidence of AKP, and improve postoperative functional outcomes.

Several studies exist that compare infrapatellar nailing to suprapatellar nailing but appropriately powered studies with objective outcomes are lacking. This international multicentered RCT aimed to determine if tibial nail insertion technique affects objective and patient reported outcome measures(PROMs) regarding post-operative knee pain after intramedullary nailing of the tibia. We randomized OTA type 42 and 43A fractures to receive infrapatellar or suprapatellar nailing and assessed patients at at 6,16,26, and 52 weeks post-operatively. The primary outcome was the visual analog scale (VAS) after kneeling; secondary outcomes included the patient-blinded Aberdeen Kneeling (AKT) and Aberdeen Standing (AST) weight distribution tests, Lysholm, Photographic Knee Pain Map (PKPM), EQ5D, knee range of motion (ROM) and Work Productivity and Activity Impairment Questionnaire (WPAI), fracture reduction, tibial alignment and union rates. The study was powered to detect a 16-point difference in the VAS kneeling test. A total of 245 patients were included in the final analysis, 128 patients were randomized to suprapatellar nailing and 117 patients to infrapatellar nailing. There were statistically significant lower VAS kneeling scores with suprapatellar nailing at all time points. The AKT demonstrated the ability to bear significantly more weight through the operative knee after suprapatellar nailing at all time points. PKPM demonstrated more pain in the patellar tendon after infrapatellar nailing and more quadriceps pain after suprapatellar nailing. There was no difference in EQ-5D, Lysholm, or WPAI. There was no difference in knee ROM between groups. Suprapatellar nailing demonstrated a significantly higher rate of anatomic fracture reduction with no differences in union rates or complication rates. This is the largest and first appropriately-powered RCT comparing suprapatellar and infrapatellar nailing. The primary outcome demonstrated significantly less knee pain at every time point up to one year after suprapatellar nailing. The patient-blinded weight distribution test demonstrated that more weight was born during kneeling in patients after suprapatellar nailing. There was a significantly higher rate of anatomic fracture reduction with suprapatellar nailing. Secondary PROMs did not demonstrate differences between treatments.

The purpose of this study is twofold: (1) to reliably define the concept of "extreme tibial nailing" and (2) assess the feasibility of tibial intramedullary nailing when the fracture extends into the nail's locking bolt zone. Design: A retrospective review. A single academic center comprised of a specialty orthopedic hospital and a Level I Trauma Center. Patient Selection Criteria: 543 patients who sustained 555 tibia fractures between February 2014 and January 2024 were reviewed by two board-certified orthopedic surgeons. Cases were classified as "extreme nailing" based on the tibial fracture within the most proximal or distal 25% of the bone such that the fracture extended into the locking bolt section of the intramedullary nail used to treat the fracture. Patients with supplemental periarticular plating of the tibia were excluded. Outcome Measures and Comparisons: Data collected included patient demographics, hospital metrics, and outcomes. Twenty-five tibial fractures treated met radiographic criterion. The "extreme IMN" cohort was 45.8years, 72% female with a mean BMI of 26.6. Over half of fractures resulted from high-energy injuries, and 40% were open. Patients were hospitalized for 92.8h on average, and the 90-day readmission rate was 8.0%. The average time to weight-bearing allowance was 5.2weeks post-op. Eight (32.0%) patients experienced complications: 12% developed fracture-related infection (FRI), 4% experienced hardware complications, and 20.0% developed nonunion requiring surgery. The rate of all-cause reoperation was 32.0%, and 28% of patients experienced knee or ankle pain at 6months or later. The rate of malalignment was 8.0%, and the average time to radiographic healing was 5.7months. Tibial nailing is an effective treatment for "extreme" tibial fractures that extend as far as the articular surface and interlocking cluster on either end. The majority of patients who underwent extreme tibial nailing recovered with acceptable alignment, minimal healing complications, and achieved radiographic union within 6months. III.