Intramedullary nailing versus percutaneous locked plating of distal extra-articular tibial fractures: a retrospective study

The aim of this study is to compare distal tibial fractures (4–10 cm proximal to the plafond) treated by intramedullary nailing with those treated by percutaneous locked plating and to assess the clinical and radiographic results, complication rates, and the need for secondary procedures. Thirty-six patients received percutaneous locked plate treatment and 25 patients received intramedullary nail treatment. The results obtained from these two treatment methods were assessed by comparing infection rates, starting time for wight-bearing, local implant irritation, union and malunion rates and along with secondary procedures. In the percutaneous locked plate group, two deep infections, four superficial infections, two nonunions, one malunion and 10 local implant irritations were observed. In the intramedullary nail group, one nonunion, four malunions and two local implant irritations were observed. The incidence of deep and superficial infections, local implant irritations and secondary procedures in the percutaneous locked plate group was greater than those in the intramedullary nail group. The time to full weight bearing was shorter in the intramedullary nail group. There was no significant statistical difference in malunion and nonunion rates between the two groups. The need for secondary procedures was more common in group receiving the percutaneous locked plate treatment and the time to full weight bearing was shorter in the intramedullary nail group.     

Outcome following distally locked volar plating for distal radius fractures with metadiaphyseal involvement

BackgroundThe surgical treatment of metadiaphyseal distal radius fractures may be difficult due to the associated articular or periarticular extension that limits standard fixation techniques. Longer distal radius volar locking plates allow stable fixation of the distal fragments while providing standard plate fixation in the proximal radius. We hypothesize that this plating technique allows adequate fixation to both the distal radius and metadiaphyseal fragments. The purpose of the study is to describe the outcomes, radiographic parameters, secondary surgeries, and complication rate with this device.MethodsA retrospective chart review was conducted on adult patients with a distal radius fracture and metadiaphyseal involvement treated with a volar, distally locked plate. All patients were followed up for radiographic union, with a mean time of 219 days (range 38–575). Fracture patterns, outcomes of range of motion, grip strength, and complications, as well as injury, post open reduction and internal fixation (ORIF), and finally, healed radiographic parameters were recorded.ResultsTwenty patients with 21 fractures were included. At union, mean radiographic parameters were the following: volar tilt of 8°, radial inclination of 27°, radial height of 14 mm, and ulnar variance of −1 mm. The mean final range of motion was 52° flexion, 50° extension, 68° pronation, and 66° supination. Complications included one infection and one plate removal. Four patients developed a nonunion requiring secondary procedures. There were no incidents of hardware failure or adhesions requiring tenolysis.ConclusionDistally locked long volar plating for metadiaphyseal distal radius fractures is a safe and effective treatment option for these complex fracture patterns allowing anatomic restoration of the radial shaft and distal radius.     

Staged external and internal locked plating for open distal tibial fractures

Background and purpose Based on reported success with staged treatment of distal tibial fractures, we designed a 2-stage protocol including external/internal locked plating. We retrospectively assessed the outcome of open distal tibial fractures treated according to this protocol.

Patients and methods From March 2006 through July 2008, 16 patients who sustained open distal tibial fractures were treated by a two-stage protocol. The first stage consisted of low-profile, locked plates for temporary external fixation after debridement and anatomic reduction, followed by soft tissue reconstruction. The second stage consisted of locked plates for definitive internal fixation, using minimally invasive percutaneous osteosynthesis. All fractures were followed for median 2 (1–3) years.

Results The reduction was classified as being good in 15 patients and fair in 1 patient. All fractures united at a median of 6 (6–12) months. At the latest follow-up, 7 patients had excellent and 9 had good Iowa ankle scores; ankle motion ranged from a median of 10 (5–20) degrees of dorsiflexion to 40 (20–60) degrees of plantar flexion.

Interpretation We believe that the 2-stage external/internal locked plating technique is an effective procedure for treatment of open distal tibial fractures in patients who need a long period of external fixation. We achieved good reduction with immediate ankle-sparing stable fixation. Soft tissue reconstruction and subsequent definitive fixation led to union of all fractures with good function.     

Comparison of functional bracing and locked intramedullary nailing in the treatment of displaced tibial shaft fractures.

Thirty-five displaced tibial shaft fractures, treated with functional bracing were compared with 43 similar fractures, treated with locked intramedullary nailing. There were 22 excellent/good results in the brace group and 38 in the nail group. There was one infection in the brace group and three in the nailed group. There were five delayed unions and two nonunions in the brace group and one delayed union in the nail group. The functional results in the nailed group were better than the braced group but locked intramedullary nailing of tibial shaft fractures require special resources and training. Locked intramedullary nailing fullfils all the functional criteria for acceptable fracture care.     

Intramedullary locked nailing for distal femoral fractures

Surgical Principles Distal femoral fractures, supracondylar and condylar fractures which can be successfully reduced by closed methods are treated with a modified method of intramedullary locked nails. Closed reduction is obtained by adducting the distal fragment and by adjusting the degree of knee flexion and extension. Condylar fractures, if present, are reduced closed and fixed with percutaneous lag screws. After preparing the medullary cavity, the distal 15 mm of the locked nail is cut away and the tip of the nail is driven to the subchondral bone of the distal femur. The advantage of this technique is the minimal dissection for these difficult fractures. The splinting effect of the intramedullary nail decreases the incidence of refracture in the geriatric patient in whom refractures are relatively common. However, this technique may not be applicable in very distal fracture and condylar fracture which cannot be reduced by closed methods, and condylar fracture in the sagittal plane.     

Unreamed locked tight-fitting nailing for acute tibial fractures

OBJECTIVES: Treatment of tibial fractures by unreamed locked nailing with loose-fitting nails has previously been shown to be associated with a low union rate and high implant failure rate. This report describes the authors' experience in using tight-fitting nails that were relatively larger than loose-fitting nails. DESIGN: Prospective cohort study. SETTING: University medical center. PATIENTS: Forty-eight consecutive patients with fifty-two tibial fractures (excluding open IIIC fractures and those with bone loss) were studied: thirty-four men and fourteen women, with a mean age of 38 years. There were twenty-five closed fractures, nine Type I, eight Type II, four Type IIIA, and six Type IIIB open fractures. INTERVENTION: Unreamed nailing with tight-fitting nails using the Russell-Taylor system. OUTCOME MEASURES: Union rate, time to union, complication rate, and functional recovery, as well as nailing time, hospital time, and crutch-walking time were recorded. RESULTS: Union occurred in forty-eight of fifty-two fractures (92%) with a mean time to union of 18.2 weeks. Compartment syndrome occurred in three patients. Deep infection occurred in one Type II and one Type IIIB open fracture. Four fractures required additional exchange nailing or bone grafting to achieve union: one Type II, one Type IIIA, and two Type IIIB open fractures. Three malalignments resulted from operative technical error. The rate of both intraoperative bony split and screw breakage was 3.8% (2 of 52), but neither complication interfered with fracture healing. Recovery of joint motion was essentially normal in those patients without knee or ankle injury. CONCLUSIONS: Unreamed locked nailing with tight-fitting nails can produce satisfactory clinical results for acute tibial fractures. It has the advantages of technical simplicity and an acceptable risk of implant failure.     

Percutaneous plating of distal tibial fractures

We studied 20 patients (mean age 47.9±3.9, range 25–85 years) undergoing percutaneous plating of the distal tibia for 43A or 43C fractures in the period 1999–2002. Bony and functional results were classified into four categories ranging from excellent to poor. Union was achieved in all but one patient. Seven patients had angular deformities between 7 and 10°, but none of these patients required further operations. No patient had a leg-length discrepancy greater than 1 cm. Thirteen patients had excellent and good bone results, and none used walking aids. Seven patients reported stiffness of the operated ankle. This reported use of percutaneous techniques in the management of fractures of the distal tibial metaphysis is preliminary. However, the functional results and the lack of soft tissue complications are encouraging.

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Résumé Nous avons étudié 20 malades (âge moyen de 47.9±3.9 ans, gamme 25 à 85) qui dans la période 1999–2002 ont eu une ostéosynthèse du tibia distal par plaque percutanée pour des fractures de type 43A ou 43C. Les résultats osseux et les résultats fonctionnels ont été classés dans quatre catégories, dexcellent à mauvais. La consolidation a été obtenue dans tous les cas sauf un. Sept malades avaient une désaxation angulaire entre 7° et 10° mais aucun na du être réopéré. Aucun malade navait une inégalité de longueur de plus dun centimètre. 13 malades avaient des résultants osseux excellents et bons, et aucun nutilise daide à la marche. Sept malades ont une raideur de la cheville opérée. Lusage de techniques percutanées dans la gestion de fractures de la métaphyse tibiale distale est préliminaire. Cependant, les résultats fonctionnels et labsence de complication au niveau des parties molles sont favorables à cette technique.

     

Percutaneous plating of distal tibial fractures

This article presents our experience with 24 patients who had distal tibial fractures and were treated by percutaneous plate fixation. Distribution of the fractures according to the AO/OTA classification was as follows: five patients suffered from a 43 A type fracture, six from a 43 B type fracture, and 13 from a 43 C type fractures. Four of the fractures were open. Exclusion criteria included 43 C3 fractures and Gustilo III open fractures. All fractures showed radiographic signs of union enough to enable full weightbearing within an average time of 12.3 weeks. All patients showed a good range of motion (average dorsiflexion 12 degrees and average plantiflexion 18 degrees). Two fractures united with mal-union: one with an 8 degrees valgus deformity and another with a 7 degrees varus deformity. Both cases, which had a metaphyseal component, were treated by means of a "soft" (flexible and manually adjustable) AO 3.5 mm reconstruction plate. Except for one case of superficial infection, no infections were detected in any of the patients. The biological percutaneous plate fixation of distal tibial fractures with no extensive intra-articular involvement is a good soft tissue preserving technique. It provides a rigid and anatomical fixation in most cases. We conclude that type B fractures with one intact column can be fixed with either "soft" or "rigid" plates, and type A and C fractures with a metaphyseal component should be fixed with "rigid" plates (AO 4.5 mm Dynamic Compression Plate). In these fractures the reduction should be performed cautiously due to the tendency of sagittal plane mal-reduction.     

Interlocking intramedullary nailing in distal tibial fractures

This retrospective study examined the results of non-pilon fractures of the distal part of the tibia treated with interlocking intramedullary nailing. Seventy-three patients with equal numbers of fractures treated surgically between 1990 and 1998 were reviewed. Mean patient age was 39.8 years, and follow-up averaged 34.2 months. The AO fracture classification system was used. Concomitant fractures of the lateral malleolus were fixed. All but three fractures achieved union within 4.2 months on average. Satisfactory or excellent results were obtained in 86.3% of patients. These results indicate interlocking intramedullary nailing is a reliable method of treatment for these fractures and is characterized by high rates of union and a low incidence of complications.     

Unreamed intramedullary nailing in distal tibial fractures

Purpose

Unreamed nailing has gained acceptance in the treatment of diaphyseal long bone fractures, especially in cases with polytrauma or high-energy injuries. Its application in distal tibial fractures, however, remains controversial.

Methods

In this study, 101 distal tibial fractures treated using closed unreamed nailing were reviewed after a mean follow-up of 32 months. There were 59 type A und 42 type B fractures. The most common fracture pattern was the A1 spiral fracture (n = 40) followed by the B2 wedge fracture (n = 18). Intra-articular extension was encountered in 14 cases. One-fourth of the patients (n = 24) had open injuries. Forty-seven patients had additional injuries, and nearly one-third of them were polytraumatised.

Results

Union occurred after a mean time of 23.9 (range, 11–134) weeks. There were 13 cases of delayed union and seven non-unions; all healed eventually with additional surgery in only six fractures. Malunion was seen in 12 cases (five valgus, two varus and five external torsion), ten of which were associated with unplated fibular fractures. Three fractures (two open) were treated for deep infection. The most common complication seen was fatigue failure of the locking screws (27 cases).

Conclusions

Unreamed nailing of distal tibial fractures is associated with a rather high rate of bone healing complications and locking screw failure. The decision for its use in the notoriously challenging fractures of this segment should be critically considered.     

Intramedullary nailing of distal metaphyseal tibial fractures

BACKGROUND: The treatment of distal metaphyseal tibial fractures remains controversial. This study was performed to evaluate the results of intramedullary nailing of distal tibial fractures located within 5 cm of the ankle joint. METHODS: Over a sixteen-month period at two institutions, thirty-six tibial fractures that involved the distal 5 cm of the tibia were treated with reamed intramedullary nailing with use of either two or three distal interlocking screws. Ten fractures with articular extension were treated with supplementary screw fixation prior to the intramedullary nailing. Radiographs were reviewed to determine the immediate and final alignments and fracture-healing. The Short Form-36 (SF-36) and Musculoskeletal Function Assessment (MFA) questionnaires were used to evaluate functional outcome. RESULTS: Acceptable radiographic alignment, defined as <5 degrees of angulation in any plane, was obtained in thirty-three patients (92%). No patient had any change in alignment between the immediate postoperative and the final radiographic evaluation. Complications included one deep infection and one iatrogenic fracture at the time of the intramedullary nailing. Six patients could not be followed. The remaining thirty fractures united at an average of 23.5 weeks. Three patients with associated traumatic bone loss underwent a staged autograft procedure, and they had fracture-healing at an average of 44.3 weeks. The functional outcome was determined at a minimum of one year for nineteen patients and at a minimum of two years (average, 4.5 years) for fifteen patients. At one year, there were significant limitations in several domains despite fracture union and maintenance of alignment, but there was improvement in the MFA scores with time. CONCLUSIONS: Intramedullary nailing is an effective alternative for the treatment of distal metaphyseal tibial fractures. Simple articular extension of the fracture is not a contraindication to intramedullary fixation. Functional outcomes improve with time.     

Stacked plating for metadiaphyseal fractures of the distal radius: a technique report

Combined injuries of the distal radius and shaft are rare, are usually caused by high energy, and pose a surgical dilemma. Surgical tactics and implants that are routinely used either for isolated fractures of the distal radius or for fractures of the radial shaft are often not applicable for this combined injury. We describe a technique of dual-stacked plating for these metadiaphyseal fractures and its use in two patients.     

Results of interlocking nailing of distal tibial fractures

Between 1982 and 1989, 117 fractures of the distal part of the lower leg were surgically treated in the Trauma Clinic belonging to the employers' liability insurance company in Frankfurt/Main. A follow-up examination of 85 of these patients, based on X-ray series, clinical reports, and insurance files, shows the functional results. Because of the high proportion of good to excellent results (95.4%), we consider fracture of the distal tibia a good indication for interlocking nailing, even from the aspect of the borderline indication of fracture in the fifth sixth. In open fractures of the distal part of the lower leg we consider the change of method from primary stabilization with external fixation to secondary interlocking nailing an appropriate procedure. The methods presented for internal fixation of fractures of the distal tibia by interlocking nailing allow early partial and full weight-bearing with the stability needed for exercising.     

Intramedullary tibial nailing in distal third tibial fractures: distal locking screws and fracture non-union

Distal third tibial fractures are prone to non-union following tibial nail insertion. The purpose of this study was to assess the union of distal third tibial fractures in patients who have undergone intra-medullary (IM) tibial nailing with one versus two distal locking screws. Sixty-five patients who had intramedullary tibial nail fixation were retrospectively analysed. Our results showed that 80% of non-unions in distal third fractures had only one distal locking screw compared to 20% who had two distal locking screws. This is statistically significant (p<0.01). We therefore conclude that two distal locking screws are essential for distal third fractures.     

CT assessment of torsion following locked intramedullary nailing of tibial fractures

The aim of our study is to determine the incidence and extent of torsional malalignment in patients with tibial diaphyseal fractures treated with closed antegrade intramedullary (IM) nailing. We measured torsion using CT scanning in 22 patients. A difference of 8 degrees or more was found in 8 cases (36%) as compared with the uninjured side. Only 2 of these cases could be clinically detected and only one patient noted the problem. We also describe a method of directly calculating torsion from CT images captured on a single film that is easy and does not require any special equipment.     

Staged external and internal locked plating for open distal tibial fractures: A retrospective study of 16 patients

Background and purpose

Based on reported success with staged treatment of distal tibial fractures, we designed a 2-stage protocol including external/internal locked plating. We retrospectively assessed the outcome of open distal tibial fractures treated according to this protocol.

Patients and methods

From March 2006 through July 2008, 16 patients who sustained open distal tibial fractures were treated by a two-stage protocol. The first stage consisted of low-profile, locked plates for temporary external fixation after debridement and anatomic reduction, followed by soft tissue reconstruction. The second stage consisted of locked plates for definitive internal fixation, using minimally invasive percutaneous osteosynthesis. All fractures were followed for median 2 (1–3) years.

Results

The reduction was classified as being good in 15 patients and fair in 1 patient. All fractures united at a median of 6 (6–12) months. At the latest follow-up, 7 patients had excellent and 9 had good Iowa ankle scores; ankle motion ranged from a median of 10 (5–20) degrees of dorsiflexion to 40 (20–60) degrees of plantar flexion.

Interpretation

We believe that the 2-stage external/internal locked plating technique is an effective procedure for treatment of open distal tibial fractures in patients who need a long period of external fixation. We achieved good reduction with immediate ankle-sparing stable fixation. Soft tissue reconstruction and subsequent definitive fixation led to union of all fractures with good function.     

Comparison of intramedullary nailing of distal third tibial shaft fractures: before and after traumatologists

We hypothesized that less malalignment and complications occur with intramedullary nailing of distal third tibia fractures (42A, B, C) after the implementation of orthopedic trauma surgeons to this level II community hospital. We also hypothesized that patients with < or =5 degrees of malalignment have poorer function as measured by the MODEMS functional outcome scale. Two cohorts of distal third tibia fractures were identified by discharge diagnosis or by the Orthopaedic Trauma Association database. Group I (n = 39) patients were stabilized with an intramedullary nail by community orthopedic surgeons. Group II (n = 18) patients were treated by orthopedic trauma surgeons. In Group I (community), 9 (23%) patients treated by the community surgeons exhibited >5 degrees of angulation in at least one direction. Five (13%) of these patients displayed angulation in more than one direction, and 3 of these patients exhibited >10 degrees of angulation. In Group II (trauma) 1 (5%) patient had >5 degrees angulation in any plane (P < .05). No differences were noted in time to union, nonunion, delayed union, hardware failure or infections between the two groups. Functional outcomes were assessed using the MODEMS lower limb module. In comparison of the patients with and without significant angulation, the P value for bodily pain was 0.042. Patients treated by the community orthopedic surgeons had a higher incidence of malalignment, as compared to those treated by orthopedic trauma specialists.     

Retrospective analysis of locked versus non-locked plating of distal fibula fractures

IntroductionUnstable distal fibular fractures have traditionally been treated with open reduction internal fixation using a 1/3 tubular non-locked plate (compression plating). Locked plating is a newer technique that has become more popular despite the lack of clinical data supporting improved outcomes. The cost of locked plating is almost four times that of compression plating. We compared rates of reoperation due to implant failure, infection, and symptomatic device between compression and locked plating in open reduction internal fixation of distal fibular fracturesMethodsA retrospective study was performed at a level one trauma center over a ten-year period (2008-2017). Patients who were 18 and older and treated for unstable ankle fractures with locking or non-locking plate were included in this study. Patient charts were reviewed by orthopedic trauma surgeons to identify whether patients were treated with a 1/3 tubular non-locking or pre-contoured locked plate and to determine the cause of reoperation.ResultsIn total, 442 patients were identified with 203 in the non-locked 1/3 tubular plate group and 239 in the pre-contoured locked plate group. A total of 38 patients (8.6%) underwent device removal with a higher proportion of patients in the non-locked 1/3 tubular plate cohort (11.3% vs. 6.3%, p = 0.059). Statistically significant differences in reasons for reoperation were found for symptomatic implant (78.3% vs. 46.7%, p = 0.045) and infection (8.7% vs 53.3%., p < 0.01). Of patients who had device removal for symptomatic implant in the compression plating cohort, 13 (72.2%) had lateral positioning and 5 (27.8%) had posterior positioning (p < 0.01) whereas there was no statistical difference in plate positioning in the locked cohort. Of all medical comorbidities identified, only diabetes was associated with a higher rate of infection-related reoperations (83.3% vs. 15.6%, p < 0.01).ConclusionsBoth compression and locked plate techniques demonstrated low reoperation rates. Compression plating with 1/3 tubular plates placed laterally more often resulted in reoperation due to symptomatic implant but had fewer complications of infection. Given that the cost is significantly less, 1/3 tubular plating placed posteriorly may be preferred to decrease the risks of symptomatic implant and infection.