Session X1 - Tibia

Intramedullary Nailing versus Percutaneous Locked Plating of Proximal Tibia Fractures: Radiographic Analysis of Accuracy of Reduction and Stability of Fixation

Eric M. Lindvall, DO; Henry C. Sagi, MD; Jeffrey Anhalt, DO;

Thomas G. DiPasquale, DO; George J. Haidukewych, MD;

Dolfi Herscovici, Jr., DO; Roy Sanders, MD; (n-all authors)

Tampa General Hospital, Tampa, Florida, USA

Purpose: To compare extraarticular proximal tibia fractures that underwent intramedullary nailing (IMN) and percutaneous locked plating (PLP) and assess the ability of each technique to obtain and maintain fracture reduction.

Materials and Methods: All extraarticular proximal tibia fractures that were treated with IMN or PLP dating back to the first use of PLP at our institution were retrospectively reviewed and compared for accuracy of reduction immediately following fixation and on final healed radiographs. Chart reviews were conducted and patients were contacted for final radiographs. Measurements were performed for frontal and sagittal plane deformities (valgus, varus, flexion and extension) by two separate physicians. The averages were recorded and comparisons were then made within and between the IMN and the PLP groups. IMN consisted of a tibial nail with a more proximal bend (Trigen- Smith/Nephew, Memphis,TN) in 20 patients and a more distal bend (Synthes, Paoli, PA) in 3 patients. PLP was performed with an anatomically designed lateral plate for the proximal tibia (L.I.S.S. — Synthes, Paoli, PA) in all 35 patients. A malreduction was defined as a deformity of > 5.0 degrees and all deformities were described in reference to the distal segment.

Results: Retrospective review yielded 23 IMN and 35 PLP cases. Average age was 40.3 years with 38 males and 10 females. Groups showed no significant difference with respect to age or sex. Five patients from each group could not be located for final radiographs, leaving 18 IMN and 30 PLP. Average follow-up for IMN and PLP was 37 months (10-66) and 26 months (9-62), respectively. There were 11 open fractures and 5 infections in the IMN group and 11 open fractures and 7 infections in the PLP group. At least one additional surgical technique was used in fracture reduction in 14/18 in the IMN group (lateral starting point -11, blocking screws- 10, femoral distractor- 1, temporary plating-1) and in 3/30 in the PLP group (femoral distractor-3). Flexion deformity was the most common complication in both groups with 12/18 malreductions in the IMN group and 5/30 in the PLP group. Average flexion deformity malreduction was 11.3 degrees in the IMN group and 12.0 degrees in the PLP group. The number of malreductions but not the severity of malreduction was statistically significant between the two groups (p=0.01). There were 4/18 IMN (ave 8.0⁰) and 3/30 PLP (ave 8.3⁰) varus malreductions and 3/18 IMN (ave 11.7) and 4/30 PLP (ave 5.0⁰) valgus malreductions. Extension deformity was rare with only one malreduction in each group IMN (5.0⁰) and PLP (8.0⁰).

Discussion/Conclusion: Comparing IMN and PLP for the treatment of extraarticular proximal tibia fractures revealed a statistically higher number of flexion deformity malreductions with IMN than with PLP. Blocking screws appeared to prevent frontal plane deformities better than sagittal plane deformities. No significant difference in ability to maintain the initial reduction was seen between treatment groups. It is therefore recommended that close intraoperative monitoring be performed to avoid a flexion deformity, especially during nail insertion.