Intramedullary Nailing of Tibial Fractures. Is There a Relationship Between the Entry Point and Its Final Alignment?
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Published:
Apr 18, 2022
Keywords:
Intramedullary nailing, tibia, misalignment
Main Article Content
Abstract
Introduction: Tibial fractures represent approximately 2% of adult fractures. Today, intramedullary nailing is the procedure of choice to treat diaphyseal fractures of the tibia; however, this technique is not exempt from complications, misalignment in the coronal plane is one of the most frequent and feared by surgeons. The aim of this study was to investigate the relationship between nail entry point and misalignment in the coronal plane after surgery.
Materials and Methods: We carried out a retrospective, descriptive, observational study between January 2015 and January 2019 of patients with diaphyseal fractures of the tibia, treated with intramedullary nailing. Radiographs were obtained in the immediate postoperative period and then every two months. The eighth-month radiograph, in which clear signs of bone consolidation could be observed, was taken into account to assess tibial alignment.
Results: When the nail entry point was central, there was only a 0.021 chance (or 2.1%) of any significant misalignment in the immediate postoperative period and after 8 months. In contrast, when it was medial, the chances of a valgus tendency were >0.85 (or 85%) already at the first image, i.e., post-surgery; and when it was lateral, this possibility was modified and deepened according to the time elapsed until the image achieved in the patient.
Conclusion: A marked and continuous relationship was observed between the entry point of the intramedullary nail and the alignment of the tibia after bone consolidation.
Materials and Methods: We carried out a retrospective, descriptive, observational study between January 2015 and January 2019 of patients with diaphyseal fractures of the tibia, treated with intramedullary nailing. Radiographs were obtained in the immediate postoperative period and then every two months. The eighth-month radiograph, in which clear signs of bone consolidation could be observed, was taken into account to assess tibial alignment.
Results: When the nail entry point was central, there was only a 0.021 chance (or 2.1%) of any significant misalignment in the immediate postoperative period and after 8 months. In contrast, when it was medial, the chances of a valgus tendency were >0.85 (or 85%) already at the first image, i.e., post-surgery; and when it was lateral, this possibility was modified and deepened according to the time elapsed until the image achieved in the patient.
Conclusion: A marked and continuous relationship was observed between the entry point of the intramedullary nail and the alignment of the tibia after bone consolidation.
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How to Cite
Nieto, I. H., Mangupli, M. M., Allende, B. L., Pioli, I. J., & Gómez, J. M. (2022). Intramedullary Nailing of Tibial Fractures. Is There a Relationship Between the Entry Point and Its Final Alignment?. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 87(2), 188-196. https://doi.org/10.15417/issn.1852-7434.2022.87.2.1495
Section
Clinical Research
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References
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https://doi.org/10.1302/0301-620X.77B3.7744927
2. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37(8):691-7.
https://doi.org/10.1016/j.injury.2006.04.130
3. Nork SE, Barei DP, Schildhauer TA, Agel J, Holt SK, Schrick JL, et al. Intramedullary nailing of proximal quarter
tibial fractures. J Orthop Trauma 2006;20(8):523-8. https://doi.org/10.1097/01.bot.0000244993.60374.d6
4. Ricci WM, O’Boyle M, Borrelli J, Bellabarba C, Sanders R. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma 2001;15(4):264-70.
https://doi.org/10.1097/00005131-200105000-00005
5. Thein E, Chevalley F, Borens O. Pseudarthrosis of the long bones. Rev Med Suisse 2013;9(411):2390-6.
https://doi.org/10.1007/s00104-017-0547-4
6. Bong MR, Kummer FJ, Koval KJ, Egol KA. Intramedullary nailing of the lower extremity: biomechanics and
biology. J Am Acad Orthop Surg 2007;15(2):97-106. https://doi.org/10.5435/00124635-200702000-00004
7. Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res 1995;(315):25-33. https://doi.org/10.1097/00003086-199506000-00004
8. Lembcke O, Ruter A, Beck A. The nail-insertion point in unreamed tibial nailing and its influence on the axial
malalignment in proximal tibial fractures. Arch Orthop Trauma Surg 2001;121(4):197-200.
https://doi.org/10.1007/s004020000200
9. Dunbar RP, Nork SE, Barei DP, Mills WJ. Provisional plating of type III open tibia fractures prior to intramedullary nailing. J Orthop Trauma 2005;19(6):412-4. https://doi.org/10.1097/01.bot.0000153446.34484.70
10. Blachut PA, O’Brien PJ, Meek RN, Broekhuyse HM. Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am 1997;79(5):640-6. https://doi.org/10.2106/00004623-199705000-00002
11. Bone LB, Kassman S, Stegemann P, France J. Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails. J Orthop Trauma 1994;8(1):45-9. https://doi.org/10.1097/00005131-199402000-00010
12. Bone LB, Johnson KD. Treatment of tibial fractures by reaming and intramedullary nailing. J Bone Joint Surg Am 1986;68(6):877-87. PMID: 3733776
13. Fan CY, Chiang CC, Chuang TY, Chui FY, Chen TH. Interlocking nails for displaced metaphyseal fractures of the
distal tibia. Injury 2005;36(5):669-74. https://doi.org/10.1016/j.injury.2004.10.018
14. Whittle AP, Wood GW. Fractures of the lower extremity. En: Canale ST (ed.). Campbell’s operative orthopaedics. St. Louis, MO: Mosby; 2003, p. 2757-61.
15. Krishan A, Peshin C, Singh D. Intramedullary nailing and plate osteosynthesis for fractures of the distal metaphyseal tibia and fibula. J Orthop Surg (Hong Kong) 2009;17(3):317-20. https://doi.org/10.1177/230949900901700315
16. Nork SE, Schwartz AK, Agel J, Holt SK, Schrick JL, Winquist RA. Intramedullary nailing of distal metaphyseal
tibial fractures. J Bone Joint Surg Am 2005;87(6):1213-21. https://doi.org/10.2106/JBJS.C.01135
17. Kruppa CG, Hoffmann MF, Sietsema DL, Mulder MB, Jones CB. Outcomes after intramedullary nailing of distal
tibial fractures. J Orthop Trauma 2015;29(9):e309-15. https://10.1097/BOT.0000000000000323
18. Franke J, Homeier A, Metz L, Wedel T, Alt V, Spät S, et al. Infrapatellar vs. suprapatellar approach to obtain an
optimal insertion angle for intramedullary nailing of tibial fractures. Eur J Trauma Emerg Surg 2018;44(6):927-38.
https://doi.org/10.1007/s00068-017-0881-8
19. Weninger P, Tschabitscher M, Traxler H, Pfafl V, Hertz H. Intramedullary nailing of proximal tibia fractures—An
anatomical study comparing three lateral starting points for nail insertion. Injury 2010;41(2):220-5.
https://doi.org/10.1016/j.injury.2009.10.014
20. Tejwani N, Polonet D, Wolinsky PR. Controversies in the intramedullary nailing of proximal and distal tibia
fractures: J Am Acad Orthop Surg 2014;22(10):665-73. https://doi.org/10.5435/JAAOS-22-10-665
https://doi.org/10.1302/0301-620X.77B3.7744927
2. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37(8):691-7.
https://doi.org/10.1016/j.injury.2006.04.130
3. Nork SE, Barei DP, Schildhauer TA, Agel J, Holt SK, Schrick JL, et al. Intramedullary nailing of proximal quarter
tibial fractures. J Orthop Trauma 2006;20(8):523-8. https://doi.org/10.1097/01.bot.0000244993.60374.d6
4. Ricci WM, O’Boyle M, Borrelli J, Bellabarba C, Sanders R. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma 2001;15(4):264-70.
https://doi.org/10.1097/00005131-200105000-00005
5. Thein E, Chevalley F, Borens O. Pseudarthrosis of the long bones. Rev Med Suisse 2013;9(411):2390-6.
https://doi.org/10.1007/s00104-017-0547-4
6. Bong MR, Kummer FJ, Koval KJ, Egol KA. Intramedullary nailing of the lower extremity: biomechanics and
biology. J Am Acad Orthop Surg 2007;15(2):97-106. https://doi.org/10.5435/00124635-200702000-00004
7. Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res 1995;(315):25-33. https://doi.org/10.1097/00003086-199506000-00004
8. Lembcke O, Ruter A, Beck A. The nail-insertion point in unreamed tibial nailing and its influence on the axial
malalignment in proximal tibial fractures. Arch Orthop Trauma Surg 2001;121(4):197-200.
https://doi.org/10.1007/s004020000200
9. Dunbar RP, Nork SE, Barei DP, Mills WJ. Provisional plating of type III open tibia fractures prior to intramedullary nailing. J Orthop Trauma 2005;19(6):412-4. https://doi.org/10.1097/01.bot.0000153446.34484.70
10. Blachut PA, O’Brien PJ, Meek RN, Broekhuyse HM. Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am 1997;79(5):640-6. https://doi.org/10.2106/00004623-199705000-00002
11. Bone LB, Kassman S, Stegemann P, France J. Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails. J Orthop Trauma 1994;8(1):45-9. https://doi.org/10.1097/00005131-199402000-00010
12. Bone LB, Johnson KD. Treatment of tibial fractures by reaming and intramedullary nailing. J Bone Joint Surg Am 1986;68(6):877-87. PMID: 3733776
13. Fan CY, Chiang CC, Chuang TY, Chui FY, Chen TH. Interlocking nails for displaced metaphyseal fractures of the
distal tibia. Injury 2005;36(5):669-74. https://doi.org/10.1016/j.injury.2004.10.018
14. Whittle AP, Wood GW. Fractures of the lower extremity. En: Canale ST (ed.). Campbell’s operative orthopaedics. St. Louis, MO: Mosby; 2003, p. 2757-61.
15. Krishan A, Peshin C, Singh D. Intramedullary nailing and plate osteosynthesis for fractures of the distal metaphyseal tibia and fibula. J Orthop Surg (Hong Kong) 2009;17(3):317-20. https://doi.org/10.1177/230949900901700315
16. Nork SE, Schwartz AK, Agel J, Holt SK, Schrick JL, Winquist RA. Intramedullary nailing of distal metaphyseal
tibial fractures. J Bone Joint Surg Am 2005;87(6):1213-21. https://doi.org/10.2106/JBJS.C.01135
17. Kruppa CG, Hoffmann MF, Sietsema DL, Mulder MB, Jones CB. Outcomes after intramedullary nailing of distal
tibial fractures. J Orthop Trauma 2015;29(9):e309-15. https://10.1097/BOT.0000000000000323
18. Franke J, Homeier A, Metz L, Wedel T, Alt V, Spät S, et al. Infrapatellar vs. suprapatellar approach to obtain an
optimal insertion angle for intramedullary nailing of tibial fractures. Eur J Trauma Emerg Surg 2018;44(6):927-38.
https://doi.org/10.1007/s00068-017-0881-8
19. Weninger P, Tschabitscher M, Traxler H, Pfafl V, Hertz H. Intramedullary nailing of proximal tibia fractures—An
anatomical study comparing three lateral starting points for nail insertion. Injury 2010;41(2):220-5.
https://doi.org/10.1016/j.injury.2009.10.014
20. Tejwani N, Polonet D, Wolinsky PR. Controversies in the intramedullary nailing of proximal and distal tibia
fractures: J Am Acad Orthop Surg 2014;22(10):665-73. https://doi.org/10.5435/JAAOS-22-10-665