ABSTRACT

Purpose. To assess the outcome of unreamed intramedullary nailing through the lateralised entry point using oblique proximal and biplanar distal interlocking screws.Methods. 15 men and 3 women aged 25 to 58 (mean, 37) years underwent unreamed intramedullary nailing with oblique proximal and biplanar distal interlocking screws for proximal third metaphyseal tibial fractures. The entry point was kept proximal to the tibial tuberosity and slightly lateral to midline. Proximal locking was at 45º to the coronal and sagittal planes. Biplanar distal locking was in the coronal and sagittal planes. Results. 16 patients had bone union within 20 (mean, 17; range, 14–27) weeks; 2 underwent dynamisation for delayed union. Three patients had valgus angulation of <5º; 2 had a loss of terminal knee flexion; 3 had a loss of ankle dorsiflexion; and 3 had shortening of >0.5 cm. Functional outcomes were excellent in 13, good in 4, and fair in one patient. No patient endured

Unreamed intramedullary nailing with oblique proximal and biplanar distal interlocking screws for proximal third tibial fractures

VK Singh,1 Y Singh,2 PK Singh,3 RK Goyal,2 H Chandra2

1 DepartmentofTraumaandOrthopaedics,LutonandDunstableHospitalsNHSFoundation2 DepartmentofTraumaandOrthopaedics,SNMedicalCollegeandHospital,Agra,India3 DepartmentofNeurovascularSurgery,RoyalHallamshireHospital,Sheffield,UnitedKingdom

Addresscorrespondenceandreprintrequeststo:MrVinayKSingh,DepartmentofTraumaandOrthopaedics,LutonandDunstableHospitalsNHSFoundationTrust,LewseyRoad,Luton,LU40DZ,UnitedKingdom.E-mail:we.publish@googlemail.com

Journal of Orthopaedic Surgery 2009;17(1):23-7

neurovascular injury, compartment syndrome or implant failure.Conclusion. Unreamed intramedullary nailing with oblique proximal and biplanar distal interlocking screws for proximal third tibial fractures was effective in preventing malalignment.

Key words: bone malalignment; fracture fixation, intramedullary; tibial fractures

INTRODUCTION

Intramedullary nailing is a well-established treatment modality for both simple and compound tibial fractures. Its indication has extended from diaphyseal fractures to proximal and distal metaphyseal fractures.1 Valgus angulation and anterior displacement are the 2 most common deformities.1–3 Malalignment is primarily due to discrepancy in size between the tibial nail and the width of the tibial metaphysis as well as displacing muscular forces acting around the fracture.1 The nail can translate laterally along coronally placed uniplanar locking screws owing to

24 VKSinghetal. Journal of Orthopaedic Surgery

the absence of nail-bone contact.4 A correct entry point is crucial in maintaining the reduction and alignment of proximal third tibial fractures. The conventional medial entry point is associated with a high rate of malalignment.1 Both reamed or unreamed nailing achieve good results.5 We assessed the outcome of unreamed intramedullary nailing through the lateralised entry point using oblique proximal and biplanar distal interlocking screws.

MATERIALS AND METHODS

From May 2000 to October 2002, 15 men and 3 women aged 25 to 58 (mean, 37) years underwent unreamed intramedullary nailing with oblique proximal and biplanar distal interlocking screws for proximal third metaphyseal tibial fractures. 14 injured the right side and 4 the left side. These injuries were secondary to traffic accidents (n=15), falls from a height (n=2) and football (n=1). 15 patients had open fractures (Gustilo classification6 type I=10, type II=3, and type IIIA=2); 3 patients had closed fractures according to Tscherne classification7 (grade-C2); 2 had segmental fractures (Fig. 1). The mean time from injury to fixation was 29 (range, 6–112) hours; in 15 patients fixation was within 24 hours of injury; in 3 it was more delayed because of associated head injury. Full-length anteroposterior and lateral radiographs of the tibia were taken to measure the diameter of the medullary canal. Stainless steel solid unreamed intramedullary nails of 8 mm (n=7) or 9 mm (n=11) in diameter were selected (Fig. 2). The leg hanging technique was used without a tourniquet. A 4-cm incision was made over the middle part of the patellar ligament (Fig. 3a). The entry point of nail insertion was just proximal to the tibial tuberosity and slightly lateral to the midline. The nail had 2 oblique proximal locking holes (anteromedial and anterolateral) at an angle of 45º to the coronal and sagittal planes, and locked with the help of a jig (Fig. 3b). The distal screws were locked first under image guidance using a free hand technique with a Steinmann pin (Fig. 3c). Knee and ankle mobilisation and static quadriceps exercises were started on postoperative day 1. Patients were kept on partial weight bearing with crutches for 6 to 8 weeks. Bone was defined as united when radiographs showed bridging callus (Fig. 4) and the patient could walk without pain. Patients were assessed clinically, radiologically (axial alignment), and functionally (using the Klemm and Borner scoring system,8 Table 1).

RESULTS

Patients were followed up for a mean of 38 (range, 20–62) months. 16 patients had bone union within 20 (mean, 17; range, 14–27) weeks; 2 underwent dynamisation for delayed union. Three patients had valgus angulation of <5º; none had anterior displacement of the proximal fragment or anteroposterior angulation. Two patients had a loss of terminal knee flexion (10º

Figure 1 Patient18:segmentalfractureofthetibia.

Figure 2 Thestainlesssteelsolidunreamedintramedullarynailandtheproximallockingjig.

Vol. 17 No. 1, April 2009 Unreamedintramedullarynailingforproximalthirdtibialfractures 25

and 20º); none had extension lag. Three patients had a loss of ankle dorsiflexion (15º in 2 and 5º in one); 3 had shortening of >0.5 cm; 2 had muscle atrophy of >1 cm in circumference. Six patients complained of pain which resolved and did not require implant

removal. Functional outcomes were excellent in 13, good in 4, and fair in one patient. One patient had a superficial wound infection, which healed after oral antibiotic therapy. No patient endured neurovascular injury, compartment syndrome or implant failure (Table 2).

DISCUSSION

Intramedullary nailing for proximal third tibial fractures is associated with a high incidence of malalignment,1,2 attributable to muscular forces, poor nail-bone contact, wrong entry portal, and translation of the nail along single plane locking screws.1 Muscles of all 3 leg compartments tend to pull small proximal fragments, predisposing the leg to valgus and anterior bowing deformities.1 A large gap between the nail and upper tibial metaphysis results in the absence of nail-cortex contact. The lack of interference fit decreases the rigidity of nail-bone construct and makes maintenance of reduction very difficult.1 The proximal tibia is triangular in shape and is

Grade Description No. (%) of patient

Excellent Fullkneeandanklemotion,nomuscleatrophy,normalalignment

13(73)

Good Slightlossofkneeandanklemotion(<25%),muscleatrophyof<2cm,angulardeformityof<5º

4(22)

Fair Moderatelossofkneeandanklemotion(≥25%),muscleatrophyof≥2cm,angulardeformityof5º–10º

1(6)

Poor Markedlossofkneeandanklemotion,markedmuscleatrophyandangulardeformity

-

Table 1Functional outcomes according to the Klemm and Borner

scoring system8

Figure 4 Patient 18: anatomic bone union with nomalalignmentat22weeks.

Figure 3 (a) The nail isinsertedfromthelateralisedentry point through themidline patellar splittingapproach. (b) Proximalscrews are locked with thehelp of the locking jig. (c)The distal screw is lockedusingafreehandtechniquewithaSteinmannpin.

(a) (b)

(c)

26 VKSinghetal. Journal of Orthopaedic Surgery

narrower medially; the anteroposterior width of the tibia is narrower on the medial side. A medial entry point may result in a valgus deformity as the nail abuts the medial cortex; varus deformity may occur when the entry portal is too lateral. The nail entry point for proximal-third tibial fractures should be either neutral or slightly lateral to the midline.1 Conventional tibial nails entail uniplanar proximal and distal locking techniques. Mediolateral screws in one plane may result in nail translation causing valgus or varus malalignment.4 Nails using oblique proximal and biplanar distal locking were alternatives to interlocking nails. In 145 tibial nail fixations, 58% of proximal third tibial fractures were malaligned, as compared to 7% of middle third and 8% of distal third fractures.1 In 32 proximal third tibial fractures treated with conventionally locked nails, 27 (84%) had an angulation of >5º in the frontal or sagittal plane, 19 (59%) had displacement of >1 cm, and 8 (25%) had a loss of fixation.2 To overcome the high rate of malalignment from conventional tibial nailing, composite fixation was advocated using a lateral plate with a medial external fixator to achieve a stable buttress opposite to the

plate.9 In 41 extra-articular comminuted proximal tibial fractures treated with composite fixation, 2% had malunion and 5% had infection. Intramedullary nailing using Poller screws may prevent malalignment in proximal and distal metaphyseal tibial fractures.10 In 21 patients treated with Poller screws, the mean varus and valgus alignment was -1º (-5º to 3º) and the mean antecurvatum-recurvatum alignment was 1.6º (-6º to 11º).10 In a cadaveric study, Poller screws increased the mechanical stability of small-diameter nails.11 The use of an AO femoral distractor before nailing of 14 proximal tibial fractures achieved a mean anterior displacement of 3 (range, 0–17) mm and a mean coronal plane alignment of 2º valgus (range, 2º varus to 12º valgus).12 In our series, the use of the lateralised entry point and oblique proximal and biplanar distal locking prevented nail translation and achieved a low rate of malalignment. The use of small-diameter unreamed nails increases the risk of malunion, as well as nail and locking screw fractures and thus the need for reoperation.13 In 50 patients treated for tibial shaft fractures, 52% broke the interlocking screws, 4% broke the nail, and 16% had malunion.13 Unreamed

Patient No.

Sex/age

(years)

Mode of injury

Type of injury

Time from injury to fixation (hours)

Nail size

(mm)

Time to union

(weeks)

Malalign-ment

Range of movement Pain Leg length discrepancy

(cm)

Compli-cations

1 M/30 RTA* TypeI 14 9x32 17 4ºvalgus Lossof15ºankledorsiflexion

Knee - -

2 M/28 RTA TypeII 8 9x34 14 - Full - - -3 M/25 RTA TypeI 99 8x34 16 - Lossof15ºankle

dorsiflexionAnkle - -

4 M/58 Football C2 20 9x32 27 - Lossof20ºkneeflexion

- - -

5 M/35 RTA TypeIIIA

6 9x30 15 - Full - 0.5 Superficialinfection

6 M/32 RTA TypeI 12 9x32 19 - Lossof10ºkneeflexion

Knee - -

7 M/40 RTA TypeII 8 9x32 16 - Full - - -8 M/45 RTA TypeI 12 8x34 16 - Full - - -9 M/42 RTA Type

IIIA14 9x34 18 4ºvalgus Full Knee - -

10 M/46 RTA TypeI 13 8x34 15 - Lossof5ºankledorsiflexion

- 0.5 -

11 F/27 RTA TypeII 110 9x34 16 - Full - - -12 F/35 RTA TypeI 12 8x34 15 - Full - - -13 F/38 Fall C2 16 9x32 14 - Full Knee - -14 M/42 RTA TypeI 24 8x32 15 - Full - - -15 M/26 Fall C2 112 8x32 15 - Full - - -16 M/32 RTA TypeI 9 9x34 25 3ºvalgus Full - - -17 M/34 RTA TypeI 18 9x34 18 - Full Ankle 0.5 -18 M/55 RTA TypeI 10 8x34 20 - Full - - -

Table 2Patient characteristics and outcomes

* RTAdenotesroadtrafficaccident

Vol. 17 No. 1, April 2009 Unreamedintramedullarynailingforproximalthirdtibialfractures 27

nailing resulted in a higher rate of failure of interlocking screws.14 None of our patients broke any locking screw or nail. Mechanical differences between unreamed and reamed nails is most significant in distal third tibial fractures.15 Screw failures are common in unreamed tibial nails for distal third tibial fractures (specially in spiral or oblique fractures).15–17 In 33 cases of tibial nailing, patients with head injury had more implant failures, due to postoperative agitation.17 Three of our patients with head injury did not have implant failure but this number is too small to derive any conclusion. Both reamed and unreamed nails have achieved

good results in type-I to type-IIIA compound tibial fractures14,15,17–20; no difference was noted in rates of infection and bone union.17

CONCLUSION

Unreamed intramedullary nailing for Gustilo type-I to type-IIIA open fractures of the proximal metaphyseal tibia was effective in preventing malalignment. The neutral to slightly lateralised entry point and oblique proximal and biplanar distal locking minimised the risks of nail translation and malalignment.

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