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The unreamed tibial nail in the treatment of distal metaphyseal fractures
PERGAMON
Injury, Int. J. Care Injured 30 (1999) 83±90
The unreamed tibial nail in the treatment of distal metaphyseal fractures R. Moshei *, O. Safran, D. Segal, M. Liebergall Orthopaedic Surgery Department, Hadassah Medical Center, Jerusalem, Israel Accepted 28 September 1998
Abstract In recent years biological surgical solutions have been recommended in cases of distal tibial fractures, with the aim of reducing damage to soft tissues and to bone vascular supply. Between the years 1991±1995, 52 patients suering from fractures of the distal tibial metaphysis were treated in our department with an unreamed tibial nail (UTN). Fractures were categorized in accordance with the AO Classi®cation. 32 fractures had no articular involvement (43A1, 43A2, 43A3) and 20 included intraarticular extension (43C1, 43C2). 32 fractures had signi®cant metaphyseal comminution (43A2, 43A3, 43C2). 12 were open fractures. All the fractures were treated by means of UTN using distal locking. In 13 patients an additional percutaneous interfragmentary ®xation was also applied. 22 patients underwent an additional operation in order to facilitate bone union (dynamization, bone grafting and/or ®bulectomy). In 50 of the 52 patients the fracture united with a very good range of knee and ankle motion. In 2 patients non-union with breakage of the UTN occurred and in two open fractures post-operative infections were observed. Our experience with the treatment of fractures of the distal tibia, including intra-articular fractures with no comminution, points at an excellent functional outcome with a low incidence of complications. # 1999 Published by Elsevier Science Ltd. All rights reserved.
1. Introduction The conservative treatment of fractures of the distal third of the tibia with extension into the ankle joint is known to result in an unacceptable deformity and ankle stiness [1, 2]. Open reduction and internal ®xation is associated with a high incidence of soft tissue complications [3]. These results have motivated orthopaedic surgeons to search for innovative techniques for minimizing bone and soft tissue problems. During the last decade more and more surgeons have been using combined external ®xation techniques for decreasing the amount of iatrogenic damage and dissection [4, 5]. Recent publications however, demonstrated a high rate of pin-tract infections, delayed unions and decreased range of ankle motion associated with external ®xation across the ankle [6, 7]. Despite these problems, intramedullary nailing is rarely advised for fractures below * Corresponding author. Tel.: +972-2-777-111.
the isthmus, on account of the risk of ankle fracture or of nail failure [8, 9]. The AO unreamed tibial nail is recommended for temporary ®xation in the treatment of fractures where the maintenance of blood supply to the bone is given priority. It oers relatively atraumatic means of closed stabilization. The medullary arterial system regenerates within a few weeks and there is signi®cantly less cortical necrosis when this loosely ®tting intramedullary nail is applied than when a snug nail after reaming is used [10]. In most cases the nail can be inserted by hand, with minimal resistance. Three distal static interlocking bolts can be inserted into three distal holes aligned in both frontal and sagittal planes and may also serve as inter-fragmentary ®xation. These are the reasons why nonreamed nails were considered to involve lower risks of devascularization, infection and impaired fracture healing and yet to serve as a sucient stabilizer of the metaphyseal component of the fracture.
0020-1383/99/$ - see front matter # 1999 Published by Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 9 8 ) 0 0 2 1 3 - 7
Sex
m f m f m m m m m m m m m m m
m m m m m m m m f f m
Patient
LB PB ER HT ZM GM CY SA MA EM MG HA SI AN SA
GA HY LC TE CY RO KE KD BA FR SS
Table 1
19 41 19 20 37 25 25 19 45 23 18
20 55 36 50 21 45 40 24 55 74 42 43 24 42 23
Age (years)
blunt trauma blunt trauma domestic fall M.V.A. twisting injury domestic fall M.V.A. penetrating wound domestic fall domestic fall domestic fall
M.V.A. M.V.A. domestic fall twisting injury twisting injury domestic fall domestic fall twisting injury blunt trauma domestic fall domstic fall twisting injury M.V.A. domestic fall twisting injury
Mechanism of injury
43A1 43A2 43A3 43C2 43C1 43A2 43A3 43C2 43C2 43A3 43A3
43A1 43A2 43A3 43A1 43A2 43A2 43A3 43A1 43C1 43C2 43C2 43C1 43A3 43C2 43A1
Distal tibial fracture (AO classi®cation)
44B2
44B2
44B2
44B2
Lateral maleolar involvement (AO classi®cation)
3C
1
1 1
2
2
Open fracture (Gustilo)
2 2 2 3 2 2 3 2 2 2 2
2 2 2 2 2 2 3 2 2 2 2 2 3 2 2
Distal-locking screws
3
2 1
2
1 1 1
Inter-fragmentary screws
plate
plate
plate
plate
Fixation of lat. maleolus
dynam.
dynam. + B.G.
dynam.
dynam.
dynam. + B.G.
dynam.
dynam.
Additional surgery
Ðcontinued
super®cial infection
breakage of nail
breakage of distal locking screw
breakage of nail
Complications
Sex
f m m f m f m
f
m m m m m m
f m m f m m m f m f f f
Patient
FL JR KY AN FY MD AH
PB
OF AM AO CY SA AD
HE HS BM CY TN SY LY YM SM HY JL OL
64 31 25 45 52 38 45 22 68 64 35 60
32 31 21 21 40 45
71
48 18 45 50 42 36 22
Age (years)
Table 1 (continued )
domestic fall M.V.A. M.V.A. M.V.A. twisting injury domestic fall M.V.A. M.V.A. M.V.A. domestic fall blunt trauma domestic fall
M.V.A. twisting injury M.V.A. twisting injury M.V.A. blunt trauma
twisting injury
domestic fall M.V.A. M.V.A. twisting injury parachuting M.V.A. blunt trauma
Mechanism of injury
43C2 43A3 43A3 43C1 43C1 43C1 43C2 43A3 43C2 43C1 43A1 43C1
43A3 43C1 43A3 43A1 43C1 43A3
43A3
43A2 43A1 43A1 43C2 43A1 43A1 43A3
Distal tibial fracture (AO classi®cation)
44B2
44B2
44C1
Lateral maleolar involvement (AO classi®cation)
3B
3A
1
1
2 3b
Open fracture (Gustilo)
3 2 3 2 2 2 2 2 3 2 2 2
3 2 2 2 2 3
3
1 2 2 2 3 2 3
Distal-locking screws
1
1
1
1
1
1
1
2
Inter-fragmentary screws
plate
plate
syndes. screw
Fixation of lat. maleolus
dynam.
dynam.
dynam. dynam. dynam.
dynam. + B.G. + ®bulectomy dynam. dynam.
dynam.
dynam. + B.G.
dynam. dynam. dynam. + B.G. + ®bulectomy
dynam. dynam.
Additional surgery
breakage of distal locking screw
deep infection
Complications
86
R. Moshei et al. / Injury, Int. J. Care Injured 30 (1999) 83±90
The unique characteristics of the AO unreamed tibial nail (Synthes AG, Switzerland) have led us to treat distal tibial fractures with no massive joint involvement by means of a combination of unreamed nailing of the metaphyseal portion and percutaneous internal ®xation of the articular surface. Only fractures with minimal extension into the ankle are suitable for this surgical technique. Since 1991 our orthopaedic trauma team has been using the AO unreamed tibial nail for the primary treatment of these fractures. We reviewed the results of our experience over a 5-year period. 2. Patients and methods We have retrospectively studied 52 patients who sustained fractures of the distal tibia and underwent surgery in our department between the years 1991±1995 (Table 1). The group included 14 women and 38 men aged 18±74 years (average 37.6). The mechanisms of injury varied. The fractures were sustained in road trac accidents (18 patients, 34%), domestic falls (16 patients, 31%), twisting injuries (11 patients, 21%), blunt trauma (5 patients, 10%), penetrating wound (1 patient, 2%) and parachuting fall (1 patient, 2%). 12 patients (23%) suered from multiple injuries. All the rest (77%) suered from isolated distal tibial fractures. Fractures were categorized according to the AO classi®cation. 32 fractures had no articular involvement (43A1, 43A2, 43A3) and 20 included intra-articular extension (43C1, 43C2). 32 fractures had signi®cant metaphyseal comminution (43A2, 43A3, 43C2). Concomitant involvement of the lateral malleolus or the syndesmosis was noted in 7 fractures and was classi®ed according to the AO/Weber classi®cation. 12 were open fractures and were classi®ed by the Gustilo system. All patients suering from an open fracture underwent debridement, followed by immediate stabilization of the fracture, within an average of 3 h (range 2 to 5 h) from the time of injury. Closed fractures were treated by means of reduction and application of a splint, followed by operative treatment within 48 h, unless severe swelling or fracture blisters were present. The average overall time from the moment of injury to the operative ®xation of the closed fractures was 3 days (range, 2 h to 8 days). All fractures were treated by AO unreamed tibial nails (Synthes AG, Switzerland) with distal locking. In all the closed fractures, the fracture was reduced by closed reduction. In 12 fractures all three distal interlocking screws were utilized. In 15 fractures with articular involvement additional percutaneous interfragmentary screws were used and in the other ®ve the interlocking screws also served as interfragmentary ®xation. In seven cases additional open reduction and in-
ternal ®xation of the distal ®bular fracture or the syndesmosis was necessary. The patients were subject to a follow-up for an average period of 18.8 months with a minimal follow-up period of 1 year. 3. Surgical technique 1. Reduction of the ®bula to restore length and axis was the initial step. Restoration of the anatomic alignment of the lateral column provided a guide to overall length of the distal tibia. 2. When necessary, percutaneous articular surface reduction with minimal periosteal stripping was performed. This step was often assisted by the use of temporary Kirschner wire ®xation. Reconstruction of the joint surface obtained with cancellous lagscrews or cannulated screws should be performed prior to insertion of the unreamed nail. The distal tibia was then converted into an essentially twopiece fracture. 3. Reduction of the proximal vertical components of the intra-articular fracture was maintained by using large reduction forceps, used percutaneously, during gentle insertion of the nail. The bone-holder was removed only after insertion of the nail. 4. Accurate closed reduction of the metaphyseal fracture was con®rmed with an image intensi®er before insertion of the nail into the distal metaphysis, at very close proximity to the subchondral plate (Fig. 1). The nail had to be inserted by hand with minimal resistance. 5. The metaphyseal portion was stabilized to the tibial diaphysis with the unreamed tibial nail and static distal interlocking was achieved with 3.9 mm bolts. No tapping was necessary. Two or three bolts serve for distal locking of the nail, and may pass across the vertical intra-articular fracture site and create an inter-fragmentary ®xation as well (Fig. 2). 4. Post operative management None of the patients were allowed any weight-bearing for a period of 6 weeks. In extra-articular fractures (43A) immediate ankle joint mobilization was encouraged under supervision of a physiotherapist. An initial short leg cast was applied for a period of 48 h. After that, in fractures with intra-articular extension (43C), activation of the ankle joint was delayed for a period of 3 weeks intervals, until clinical and radiological union was con®rmed. Patients then returned for follow-up visits every 3 months during the ®rst year and every 6 months thereafter. Serial radiographs were made during the follow-up visits at the clinic and were evaluated for callus formation and the development of
R. Moshei et al. / Injury, Int. J. Care Injured 30 (1999) 83±90
87
Fig. 1. Immediate postoperative radiographs of a type-C2 fracture show two locking screws and an inter-fragmentary lag-screw inserted via the medial malleolus (a, antero-posterior view, b, lateral view).
angulation, rotation, shortening or post-traumatic arthritis. In cases of extra-articular fractures with no comminution or when signs of bone union were observed, patients were allowed to walk with full weight bearing after a postoperative period of 6 weeks. In cases of intra-articular involvement full weight bearing was postponed for 6 more weeks. In cases of signi®cant metaphyseal bone-loss patients underwent additional surgical procedure to facilitate bone union and walked with toe-touch weight bearing for an additional 6 weeks. Removal of the UTN was performed after a period of 1 to 2 years from the day of the operation.
5. Additional surgical procedures 22 out of the 52 patients who had been operated on underwent additional surgical procedures to facilitate bone union. These procedures were performed 6 weeks to 4 months after the tibial nailing (an average of 2.4 months). Routine procedure in all cases included dynamization of the fracture by removal of interlocking
screws (Fig. 3). In six cases autologous bone grafting was performed and two of the patients also underwent ®bulectomy. Exchange of the UTN to a reamed nail was not included in our protocol due to the short distal segment and the proximity of the metaphyseal fracture to the ankle joint.
6. Results 50 fractures united. The mean time of union was 15.3 weeks (12±54). The time of union was similar in the various types of fractures, according to the AO classi®cation. Yet, additional surgical procedures were applied in 14 cases with signi®cant metaphysial comminution (43%), whereas 8 patients with no metaphyseal bone-loss needed additional surgery (40%). Dynamization by removal of interlocking screws only was sucient for fractures with no comminution, whereas ®ve fractures with metaphyseal bone-loss needed additional bone grafting and two of them underwent ®bulectomy as well.
88
R. Moshei et al. / Injury, Int. J. Care Injured 30 (1999) 83±90
Fig. 2. (a) Postoperative radiograph of a type-A3 fracture shows the use of three locking screws. The proximal screw exerting a lag eect. (b) Postoperative radiograph of a type-C1 fracture. Fixation of the articular surface is achieved by two additional cannulated screws. (c) Postoperative radiograph of a type-A1 fracture with involvement of the syndesmosis.
R. Moshei et al. / Injury, Int. J. Care Injured 30 (1999) 83±90
89
7. Discussion The introduction of new techniques for nailing of tibial fractures has extended the range of fractures for which this form of treatment is suitable [11±13]. Complications occurring in the traditional methods of internal ®xation of fractures of the distal tibia, have directed research towards biological solutions which can prevent damage of the soft tissue and the vascular supply in the vicinity of the fracture [10]. Based on this information we started, 5 years ago, to utilize the AO unreamed tibial nail for treatment of fractures of the distal tibia with or without intra-articular involvement. Very little experience is known to exist in the use of reamed nails for treatment of such fractures. Moreover, publications on the use of this method point at quite a number of both mechanical and other complications. Our successful experience clearly shows the advantages of using the unreamed nail for treatment of these fractures:
Fig. 3. Dynamization of the UTN to promote union is performed 2 months after surgery.
A radiological review revealed no shortening of the injured limb, no rotational, varus or valgus deformities. All the intra-articular fractures healed without displacement. Two patients who did not observe the regular follow-up and did not receive treatment in accordance with our protocol, returned to our clinic (after 6 and 9 months, respectively) with non-union and concomitant breakage of the UTN. This necessitated replacement of the broken nails with reamed nails which resulted in full bone-union. In two other patients we observed breakage of distal interlocking screws with no delay in bone union. Of the 12 open fractures, one fracture (grade 3B) developed a deep infection and required surgical debridement. In another patient with an open fracture (grade 2), a super®cial infection was observed and was treated successfully with antibiotics. Most of the patients regained full range of anklejoint motion. A small limitation (less than 5 degrees in comparison to the contralateral ankle joint) was observed in only 5 patients. No limitation of the knee range of motion was observed.
1. Unreamed nailing produces a biological ®xation with no harm done to the endosteal vascular supply. 2. The structure of the nail enables distal locking by means of three interlocking screws which are placed at a distance of 2±4 cm from its distal end. 3. The narrow diameter of the nail enables the percutaneous insertion of additional interfragmentary screws. 4. The biomechanical weakness of the nail does not interfere with the patient's recovery, since in any event, immediate weight bearing is not permitted in distal tibial fractures. A small number of complications was observed in this series and included two cases of broken nails due to non-union of the fracture. This can be attributed to the prevention of weight-bearing and to the close follow-up aimed at identifying cases of delayed union. In most cases, success of the treatment depends on an aggressive approach, including additional surgical procedures to promote union (bone grafting, dynamization, ®bulectomy). It is worthwhile to note that in the last 2 years, dynamization of the UTN 2 months after surgery, has become a routine procedure in our department. Recently, several papers have noted the preference of reamed nails over unreamed nails for treatment of fractures of the tibia [14]. Our paper refers to a speci®c case in which unreamed nails are used for distal fractures of the tibia and where the advantages of unreamed nails are demonstrated. The use of UTN for treatment of fractures of the distal tibial metaphysis provides sucient mechanical stability and early bone union without endangering the
90
R. Moshei et al. / Injury, Int. J. Care Injured 30 (1999) 83±90
soft tissues. Our experience with fractures of the distal tibia in cases of articular involvement also indicates an excellent functional outcome, good range of ankle joint motion and low incidence of complications.
References [1] Bourne RB, Rorabeck CH, Macnab J. Intra-articular fractures of the distal tibia: the pilon fracture. J. Trauma 1983;23:591±6. [2] Brumback RJ, McGarvey WC. Fractures of the tibial plafond. Evolving treatment concepts for the pilon fracture. Orthop. Clin. North Am. 1995;26(2):273±85. [3] Teeny SM, Wiss DA. Open reduction and internal ®xation of tibial plafond fractures: variables contributing to poor results and complications. Clin. Orthop. 1993;292:108±17. [4] Murphy CP, D'Ambrosia R, Dabezies EJ. The small pin circular ®xator for distal tibial pilon fractures with soft tissue compromise. Orthopedics 1991;14:283±90. [5] Saleh M, Shanahan MDG, Fern ED. Intra-articular fractures of the distal tibia: surgical management by limited internal ®xation and articulated distraction. Injury 1993;24(1):37±40. [6] Schwartsman V, Martin SN, Ronquist RA, Schwartsman R. Tibial fractures. The Ilizarov alternative. Clin. Orthop. 1992;278:207±16.
[7] Tucker HI, Kendra JC, Kinnebrew TE. Management of unstable open and closed tibial fractures using the Ilizarov method. Clin. Orthop. 1992;280:125±35. [8] Bostman O, Hanninen A. A ®bular reciprocal fracture in tibial shaft fractures caused by indirect violence. Arch. Orthop. Trauma Surg. 1982;100:115±21. [9] Hahn D, Bradbury N, Hartely R, Radford PJ. Intramedullary nail breakage in distal fractures of the tibia. Injury 1996;27(5):323±7. [10] Klein MP, Rahn BA, Frigg R, Kessler S, Perren SM. Reaming versus non-reaming in medullary nailing: interference with cortical circulation of the canine tibia. Arch. Orthop. Trauma Surg. 1990;109(6):314±6. [11] Vecsei V, Scharf W, Hertz H. Use of interlocking nail for the treatment of distal diaphyseal fractures of the lower leg. Unfallheielkunde 1980;83:54±9. [12] Bostman O, Vajnionpaa S, Saikku K. Infra-istmal longitudinal fractures of tibial diaphysis: results of treatment using closed intramedullary compression nailing. J. Trauma 1984;24(11):964± 9. [13] Robinson CM, McLauchlan GJ, McLean IP, Court CM. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classi®cation and treatment by locked intramedullary nailing. J. Bone Joint Surg. B 1995;77(5):781±7. [14] Court-Brown CM, McQueen MM, Quaba AA, Christie J. Locked intramedullary nailing of open tibial fractures. J. Bone Joint Surg. B 1991;73(6):959±64.
Injury, Int. J. Care Injured 30 (1999) 83±90
The unreamed tibial nail in the treatment of distal metaphyseal fractures R. Moshei *, O. Safran, D. Segal, M. Liebergall Orthopaedic Surgery Department, Hadassah Medical Center, Jerusalem, Israel Accepted 28 September 1998
Abstract In recent years biological surgical solutions have been recommended in cases of distal tibial fractures, with the aim of reducing damage to soft tissues and to bone vascular supply. Between the years 1991±1995, 52 patients suering from fractures of the distal tibial metaphysis were treated in our department with an unreamed tibial nail (UTN). Fractures were categorized in accordance with the AO Classi®cation. 32 fractures had no articular involvement (43A1, 43A2, 43A3) and 20 included intraarticular extension (43C1, 43C2). 32 fractures had signi®cant metaphyseal comminution (43A2, 43A3, 43C2). 12 were open fractures. All the fractures were treated by means of UTN using distal locking. In 13 patients an additional percutaneous interfragmentary ®xation was also applied. 22 patients underwent an additional operation in order to facilitate bone union (dynamization, bone grafting and/or ®bulectomy). In 50 of the 52 patients the fracture united with a very good range of knee and ankle motion. In 2 patients non-union with breakage of the UTN occurred and in two open fractures post-operative infections were observed. Our experience with the treatment of fractures of the distal tibia, including intra-articular fractures with no comminution, points at an excellent functional outcome with a low incidence of complications. # 1999 Published by Elsevier Science Ltd. All rights reserved.
1. Introduction The conservative treatment of fractures of the distal third of the tibia with extension into the ankle joint is known to result in an unacceptable deformity and ankle stiness [1, 2]. Open reduction and internal ®xation is associated with a high incidence of soft tissue complications [3]. These results have motivated orthopaedic surgeons to search for innovative techniques for minimizing bone and soft tissue problems. During the last decade more and more surgeons have been using combined external ®xation techniques for decreasing the amount of iatrogenic damage and dissection [4, 5]. Recent publications however, demonstrated a high rate of pin-tract infections, delayed unions and decreased range of ankle motion associated with external ®xation across the ankle [6, 7]. Despite these problems, intramedullary nailing is rarely advised for fractures below * Corresponding author. Tel.: +972-2-777-111.
the isthmus, on account of the risk of ankle fracture or of nail failure [8, 9]. The AO unreamed tibial nail is recommended for temporary ®xation in the treatment of fractures where the maintenance of blood supply to the bone is given priority. It oers relatively atraumatic means of closed stabilization. The medullary arterial system regenerates within a few weeks and there is signi®cantly less cortical necrosis when this loosely ®tting intramedullary nail is applied than when a snug nail after reaming is used [10]. In most cases the nail can be inserted by hand, with minimal resistance. Three distal static interlocking bolts can be inserted into three distal holes aligned in both frontal and sagittal planes and may also serve as inter-fragmentary ®xation. These are the reasons why nonreamed nails were considered to involve lower risks of devascularization, infection and impaired fracture healing and yet to serve as a sucient stabilizer of the metaphyseal component of the fracture.
0020-1383/99/$ - see front matter # 1999 Published by Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 9 8 ) 0 0 2 1 3 - 7
Sex
m f m f m m m m m m m m m m m
m m m m m m m m f f m
Patient
LB PB ER HT ZM GM CY SA MA EM MG HA SI AN SA
GA HY LC TE CY RO KE KD BA FR SS
Table 1
19 41 19 20 37 25 25 19 45 23 18
20 55 36 50 21 45 40 24 55 74 42 43 24 42 23
Age (years)
blunt trauma blunt trauma domestic fall M.V.A. twisting injury domestic fall M.V.A. penetrating wound domestic fall domestic fall domestic fall
M.V.A. M.V.A. domestic fall twisting injury twisting injury domestic fall domestic fall twisting injury blunt trauma domestic fall domstic fall twisting injury M.V.A. domestic fall twisting injury
Mechanism of injury
43A1 43A2 43A3 43C2 43C1 43A2 43A3 43C2 43C2 43A3 43A3
43A1 43A2 43A3 43A1 43A2 43A2 43A3 43A1 43C1 43C2 43C2 43C1 43A3 43C2 43A1
Distal tibial fracture (AO classi®cation)
44B2
44B2
44B2
44B2
Lateral maleolar involvement (AO classi®cation)
3C
1
1 1
2
2
Open fracture (Gustilo)
2 2 2 3 2 2 3 2 2 2 2
2 2 2 2 2 2 3 2 2 2 2 2 3 2 2
Distal-locking screws
3
2 1
2
1 1 1
Inter-fragmentary screws
plate
plate
plate
plate
Fixation of lat. maleolus
dynam.
dynam. + B.G.
dynam.
dynam.
dynam. + B.G.
dynam.
dynam.
Additional surgery
Ðcontinued
super®cial infection
breakage of nail
breakage of distal locking screw
breakage of nail
Complications
Sex
f m m f m f m
f
m m m m m m
f m m f m m m f m f f f
Patient
FL JR KY AN FY MD AH
PB
OF AM AO CY SA AD
HE HS BM CY TN SY LY YM SM HY JL OL
64 31 25 45 52 38 45 22 68 64 35 60
32 31 21 21 40 45
71
48 18 45 50 42 36 22
Age (years)
Table 1 (continued )
domestic fall M.V.A. M.V.A. M.V.A. twisting injury domestic fall M.V.A. M.V.A. M.V.A. domestic fall blunt trauma domestic fall
M.V.A. twisting injury M.V.A. twisting injury M.V.A. blunt trauma
twisting injury
domestic fall M.V.A. M.V.A. twisting injury parachuting M.V.A. blunt trauma
Mechanism of injury
43C2 43A3 43A3 43C1 43C1 43C1 43C2 43A3 43C2 43C1 43A1 43C1
43A3 43C1 43A3 43A1 43C1 43A3
43A3
43A2 43A1 43A1 43C2 43A1 43A1 43A3
Distal tibial fracture (AO classi®cation)
44B2
44B2
44C1
Lateral maleolar involvement (AO classi®cation)
3B
3A
1
1
2 3b
Open fracture (Gustilo)
3 2 3 2 2 2 2 2 3 2 2 2
3 2 2 2 2 3
3
1 2 2 2 3 2 3
Distal-locking screws
1
1
1
1
1
1
1
2
Inter-fragmentary screws
plate
plate
syndes. screw
Fixation of lat. maleolus
dynam.
dynam.
dynam. dynam. dynam.
dynam. + B.G. + ®bulectomy dynam. dynam.
dynam.
dynam. + B.G.
dynam. dynam. dynam. + B.G. + ®bulectomy
dynam. dynam.
Additional surgery
breakage of distal locking screw
deep infection
Complications
86
R. Moshei et al. / Injury, Int. J. Care Injured 30 (1999) 83±90
The unique characteristics of the AO unreamed tibial nail (Synthes AG, Switzerland) have led us to treat distal tibial fractures with no massive joint involvement by means of a combination of unreamed nailing of the metaphyseal portion and percutaneous internal ®xation of the articular surface. Only fractures with minimal extension into the ankle are suitable for this surgical technique. Since 1991 our orthopaedic trauma team has been using the AO unreamed tibial nail for the primary treatment of these fractures. We reviewed the results of our experience over a 5-year period. 2. Patients and methods We have retrospectively studied 52 patients who sustained fractures of the distal tibia and underwent surgery in our department between the years 1991±1995 (Table 1). The group included 14 women and 38 men aged 18±74 years (average 37.6). The mechanisms of injury varied. The fractures were sustained in road trac accidents (18 patients, 34%), domestic falls (16 patients, 31%), twisting injuries (11 patients, 21%), blunt trauma (5 patients, 10%), penetrating wound (1 patient, 2%) and parachuting fall (1 patient, 2%). 12 patients (23%) suered from multiple injuries. All the rest (77%) suered from isolated distal tibial fractures. Fractures were categorized according to the AO classi®cation. 32 fractures had no articular involvement (43A1, 43A2, 43A3) and 20 included intra-articular extension (43C1, 43C2). 32 fractures had signi®cant metaphyseal comminution (43A2, 43A3, 43C2). Concomitant involvement of the lateral malleolus or the syndesmosis was noted in 7 fractures and was classi®ed according to the AO/Weber classi®cation. 12 were open fractures and were classi®ed by the Gustilo system. All patients suering from an open fracture underwent debridement, followed by immediate stabilization of the fracture, within an average of 3 h (range 2 to 5 h) from the time of injury. Closed fractures were treated by means of reduction and application of a splint, followed by operative treatment within 48 h, unless severe swelling or fracture blisters were present. The average overall time from the moment of injury to the operative ®xation of the closed fractures was 3 days (range, 2 h to 8 days). All fractures were treated by AO unreamed tibial nails (Synthes AG, Switzerland) with distal locking. In all the closed fractures, the fracture was reduced by closed reduction. In 12 fractures all three distal interlocking screws were utilized. In 15 fractures with articular involvement additional percutaneous interfragmentary screws were used and in the other ®ve the interlocking screws also served as interfragmentary ®xation. In seven cases additional open reduction and in-
ternal ®xation of the distal ®bular fracture or the syndesmosis was necessary. The patients were subject to a follow-up for an average period of 18.8 months with a minimal follow-up period of 1 year. 3. Surgical technique 1. Reduction of the ®bula to restore length and axis was the initial step. Restoration of the anatomic alignment of the lateral column provided a guide to overall length of the distal tibia. 2. When necessary, percutaneous articular surface reduction with minimal periosteal stripping was performed. This step was often assisted by the use of temporary Kirschner wire ®xation. Reconstruction of the joint surface obtained with cancellous lagscrews or cannulated screws should be performed prior to insertion of the unreamed nail. The distal tibia was then converted into an essentially twopiece fracture. 3. Reduction of the proximal vertical components of the intra-articular fracture was maintained by using large reduction forceps, used percutaneously, during gentle insertion of the nail. The bone-holder was removed only after insertion of the nail. 4. Accurate closed reduction of the metaphyseal fracture was con®rmed with an image intensi®er before insertion of the nail into the distal metaphysis, at very close proximity to the subchondral plate (Fig. 1). The nail had to be inserted by hand with minimal resistance. 5. The metaphyseal portion was stabilized to the tibial diaphysis with the unreamed tibial nail and static distal interlocking was achieved with 3.9 mm bolts. No tapping was necessary. Two or three bolts serve for distal locking of the nail, and may pass across the vertical intra-articular fracture site and create an inter-fragmentary ®xation as well (Fig. 2). 4. Post operative management None of the patients were allowed any weight-bearing for a period of 6 weeks. In extra-articular fractures (43A) immediate ankle joint mobilization was encouraged under supervision of a physiotherapist. An initial short leg cast was applied for a period of 48 h. After that, in fractures with intra-articular extension (43C), activation of the ankle joint was delayed for a period of 3 weeks intervals, until clinical and radiological union was con®rmed. Patients then returned for follow-up visits every 3 months during the ®rst year and every 6 months thereafter. Serial radiographs were made during the follow-up visits at the clinic and were evaluated for callus formation and the development of
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Fig. 1. Immediate postoperative radiographs of a type-C2 fracture show two locking screws and an inter-fragmentary lag-screw inserted via the medial malleolus (a, antero-posterior view, b, lateral view).
angulation, rotation, shortening or post-traumatic arthritis. In cases of extra-articular fractures with no comminution or when signs of bone union were observed, patients were allowed to walk with full weight bearing after a postoperative period of 6 weeks. In cases of intra-articular involvement full weight bearing was postponed for 6 more weeks. In cases of signi®cant metaphyseal bone-loss patients underwent additional surgical procedure to facilitate bone union and walked with toe-touch weight bearing for an additional 6 weeks. Removal of the UTN was performed after a period of 1 to 2 years from the day of the operation.
5. Additional surgical procedures 22 out of the 52 patients who had been operated on underwent additional surgical procedures to facilitate bone union. These procedures were performed 6 weeks to 4 months after the tibial nailing (an average of 2.4 months). Routine procedure in all cases included dynamization of the fracture by removal of interlocking
screws (Fig. 3). In six cases autologous bone grafting was performed and two of the patients also underwent ®bulectomy. Exchange of the UTN to a reamed nail was not included in our protocol due to the short distal segment and the proximity of the metaphyseal fracture to the ankle joint.
6. Results 50 fractures united. The mean time of union was 15.3 weeks (12±54). The time of union was similar in the various types of fractures, according to the AO classi®cation. Yet, additional surgical procedures were applied in 14 cases with signi®cant metaphysial comminution (43%), whereas 8 patients with no metaphyseal bone-loss needed additional surgery (40%). Dynamization by removal of interlocking screws only was sucient for fractures with no comminution, whereas ®ve fractures with metaphyseal bone-loss needed additional bone grafting and two of them underwent ®bulectomy as well.
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Fig. 2. (a) Postoperative radiograph of a type-A3 fracture shows the use of three locking screws. The proximal screw exerting a lag eect. (b) Postoperative radiograph of a type-C1 fracture. Fixation of the articular surface is achieved by two additional cannulated screws. (c) Postoperative radiograph of a type-A1 fracture with involvement of the syndesmosis.
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7. Discussion The introduction of new techniques for nailing of tibial fractures has extended the range of fractures for which this form of treatment is suitable [11±13]. Complications occurring in the traditional methods of internal ®xation of fractures of the distal tibia, have directed research towards biological solutions which can prevent damage of the soft tissue and the vascular supply in the vicinity of the fracture [10]. Based on this information we started, 5 years ago, to utilize the AO unreamed tibial nail for treatment of fractures of the distal tibia with or without intra-articular involvement. Very little experience is known to exist in the use of reamed nails for treatment of such fractures. Moreover, publications on the use of this method point at quite a number of both mechanical and other complications. Our successful experience clearly shows the advantages of using the unreamed nail for treatment of these fractures:
Fig. 3. Dynamization of the UTN to promote union is performed 2 months after surgery.
A radiological review revealed no shortening of the injured limb, no rotational, varus or valgus deformities. All the intra-articular fractures healed without displacement. Two patients who did not observe the regular follow-up and did not receive treatment in accordance with our protocol, returned to our clinic (after 6 and 9 months, respectively) with non-union and concomitant breakage of the UTN. This necessitated replacement of the broken nails with reamed nails which resulted in full bone-union. In two other patients we observed breakage of distal interlocking screws with no delay in bone union. Of the 12 open fractures, one fracture (grade 3B) developed a deep infection and required surgical debridement. In another patient with an open fracture (grade 2), a super®cial infection was observed and was treated successfully with antibiotics. Most of the patients regained full range of anklejoint motion. A small limitation (less than 5 degrees in comparison to the contralateral ankle joint) was observed in only 5 patients. No limitation of the knee range of motion was observed.
1. Unreamed nailing produces a biological ®xation with no harm done to the endosteal vascular supply. 2. The structure of the nail enables distal locking by means of three interlocking screws which are placed at a distance of 2±4 cm from its distal end. 3. The narrow diameter of the nail enables the percutaneous insertion of additional interfragmentary screws. 4. The biomechanical weakness of the nail does not interfere with the patient's recovery, since in any event, immediate weight bearing is not permitted in distal tibial fractures. A small number of complications was observed in this series and included two cases of broken nails due to non-union of the fracture. This can be attributed to the prevention of weight-bearing and to the close follow-up aimed at identifying cases of delayed union. In most cases, success of the treatment depends on an aggressive approach, including additional surgical procedures to promote union (bone grafting, dynamization, ®bulectomy). It is worthwhile to note that in the last 2 years, dynamization of the UTN 2 months after surgery, has become a routine procedure in our department. Recently, several papers have noted the preference of reamed nails over unreamed nails for treatment of fractures of the tibia [14]. Our paper refers to a speci®c case in which unreamed nails are used for distal fractures of the tibia and where the advantages of unreamed nails are demonstrated. The use of UTN for treatment of fractures of the distal tibial metaphysis provides sucient mechanical stability and early bone union without endangering the
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soft tissues. Our experience with fractures of the distal tibia in cases of articular involvement also indicates an excellent functional outcome, good range of ankle joint motion and low incidence of complications.
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[7] Tucker HI, Kendra JC, Kinnebrew TE. Management of unstable open and closed tibial fractures using the Ilizarov method. Clin. Orthop. 1992;280:125±35. [8] Bostman O, Hanninen A. A ®bular reciprocal fracture in tibial shaft fractures caused by indirect violence. Arch. Orthop. Trauma Surg. 1982;100:115±21. [9] Hahn D, Bradbury N, Hartely R, Radford PJ. Intramedullary nail breakage in distal fractures of the tibia. Injury 1996;27(5):323±7. [10] Klein MP, Rahn BA, Frigg R, Kessler S, Perren SM. Reaming versus non-reaming in medullary nailing: interference with cortical circulation of the canine tibia. Arch. Orthop. Trauma Surg. 1990;109(6):314±6. [11] Vecsei V, Scharf W, Hertz H. Use of interlocking nail for the treatment of distal diaphyseal fractures of the lower leg. Unfallheielkunde 1980;83:54±9. [12] Bostman O, Vajnionpaa S, Saikku K. Infra-istmal longitudinal fractures of tibial diaphysis: results of treatment using closed intramedullary compression nailing. J. Trauma 1984;24(11):964± 9. [13] Robinson CM, McLauchlan GJ, McLean IP, Court CM. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classi®cation and treatment by locked intramedullary nailing. J. Bone Joint Surg. B 1995;77(5):781±7. [14] Court-Brown CM, McQueen MM, Quaba AA, Christie J. Locked intramedullary nailing of open tibial fractures. J. Bone Joint Surg. B 1991;73(6):959±64.