Sat., 10/6/12 Tibial Fractures, PAPER #116, 4:15 pm OTA-2012
Intramedullary Nailing for Distal Tibial Fractures
Christiane G. Kruppa, MD1; Martin F. Hoffmann, MD1; Michelle B. Mulder, BS2;
Debra L. Sietsema, PhD3; Clifford B. Jones, MD3;
1Grand Rapids Medical Education Partners, Grand Rapids, Michigan, USA;
2Wayne State University, Detroit, Michigan, USA;
3Orthopaedic Associates of Michigan, Michigan State University, Grand Rapids, Michigan, USA
Background/Purpose: Locked intramedullary nailing is considered the treatment of choice in diaphyseal tibial fractures. With accumulation of experience with tibial nails and the ability of multiplanar locking in varying directions, the indication for intramedullary nailing was gradually expanded to include more cases of distal tibial fractures. The difference in size between the implant diameter and the metaphyseal diameter results in small nail-cortex contact and diminished cortical bone support of the distal tibia limits the construct stability. The purpose of this study was to elucidate postoperative radiographic alignment, nonunion rates, and clinical outcome (range of motion) after intramedullary nailing for distal tibial fractures.
Methods: From 2002 to 2010, 239 consecutive patients with intramedullary nail–treated distal tibial fractures (<11 cm from the joint line, OTA 43) were retrospectively evaluated. Patients were followed in a single large private orthopaedic practice affiliated with a Level I trauma center. Excluded patients were related to initial amputation (1), existing ankle arthrodesis (1), no follow-up (10), and follow-up less than 10 months (105), as well as insufficient radiologic and chart data (17). Therefore, the final study group consisted of 105 distal tibial fractures. Injuries were classified as 52 A1, 13 A2, 9 A3, 25 C1, 5 C2, and 1 C3 according to the OTA/AO 43 classification. Comorbidities and risk factors were recorded. Patients were evaluated clinically (range of motion, pain, return to work) and radiographically at regular intervals of 2 weeks, 6 weeks, 12 weeks, 6 months, and 1 year. Varus/valgus and sagittal alignment were measured on the final radiographs.
Results: The study population consisted of 57 male (54.3%) and 48 female patients (45.7%), with 43 left (40.9%) and 62 right leg injuries (59.1%). Mean age was 43.1 years (range, 18-89). The body mass index averaged 27.3 kg/m2. Mean follow-up was 25.6 months (range, 10-74). The majority of the injuries were caused by high-energy trauma (61.9%), with 33 open fractures (31.4%). The average distance to the joint line was 6.1 cm (range, 0-10.9 cm). An accompanying fibula fracture was diagnosed in 101 and treated in 40 patients with plating (26) or rush pin (14). Nonunion occurred in 20 patients (19%). 33.3% of the nonunions occurred in open fractures (P = 0.14). Nonunions were significantly associated with open fractures (P = 0.014), wound complications (P <0.001), and fibular fixation (P = 0.007). Hardware removal was performed in 52 patients (36 nails, 16 screws). Radiographic evaluation showed a mean AP angulation of 2.5° valgus, with 4 patients having >5° varus and 21 patients >5° valgus. The joint line in the lateral view averaged 88.6°. Range of motion averaged 15.1° (range, 0°-30°) of dorsiflexion and 37.9° (range, 3°-50°) of plantar flexion. Knee pain occurred in 24 patients. The average knee range of motion was 0° of extension and 140° of flexion (range, –10°-150°).
Conclusion: Intramedullary nailing of distal tibial fractures is a treatment option for specific indications. Stable fixation with good alignment and range of motion can be achieved. A nonunion rate of 19% is high. Nonunions were significantly associated with open fractures, wound complications, and fibular fixation.
Alphabetical Disclosure Listing (808K PDF)
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.