Session IX - Tibia

Unreamed Nailing for Segmental Tibia Fractures: A Prospective Study

Paul Tornetta, III, MD; Steve Nguyen, MD, Boston University Medical Center, Boston, MA

Purpose: Segmental tibia fractures are reported to have high complication rates and their treatment is controversial. Slow time to union and difficulty holding a reduction in a cast or functional brace have led most surgeons to treat these fractures operatively. However, there is little information regarding the outcome of different treatment methods and virtually no prospective studies reported for this injury. The purpose of this study is to report a large series of segmental tibia fractures treated with a single technique.

Materials and Methods: Sixty-two consecutive patients with segmental tibia fractures (OTA type 42-C2) were entered into a prospective protocol which included stabilization with an unreamed titanium tibial nail. Fractures proximal to the tubercle and those within 3 cm of the ankle were excluded. The average age of the patients was 44 (16 - 90). The mechanism of injury was pedestrian struck (40), MVA (16), other (6); 28 patients had associated injuries. There were 36 open [3A (32), 3B (4)] and 26 closed fractures. Six fractures were associated with compartment syndromes and underwent four compartment fasciotomy prior to nailing; 5 of these 6 were in open fractures. Nailing was performed using standard techniques on a radiolucent table. A femoral distractor was used in 16 cases to aid in the reduction. Small titanium nails [8mm (15), 9mm (42), 10mm (5)] were used in an effort to provide an internal splint while avoiding a tight peripheral fit. Cortical contact of the fracture fragments was considered desirable and was obtained in all but 7 fractures. Shortening of up to 1 cm was accepted to achieve this goal. Weightbearing was begun at 8 - 12 weeks. Secondary procedures were offered if there was no callus at 3 months, or if there was no progression toward union for 2 months thereafter.

Results: Three patients died as a result of multiple injuries in the immediate perioperative period. Forty-three fractures were within 5 cm of the proximal locking screws and 31 were within 5 cm of the distal locking screws (21 had both). Three fractures were fixed in > 5° of angulation. Thirty-eight additional fractures had angulation of the intermediate segment only without any change in the normal relationship of the knee to the ankle. The 47 fractures that have united to date have been followed for an average of 3.2 years. An additional 6 fractures are progressing towards union at the time of writing and 6 were lost to follow-up. The average time to union was 159 days. Closed fractures healed faster than open fractures (138 vs. 178 days). Fractures associated with compartment syndrome and type 3B open fractures had the longest time to union, averaging 294 days (145 - 587). The proximal fracture healed first in 41 (87%) of the patients. FWB was achieved within 3 months for all closed and 74% of the open fractures. For the entire group, 10 patients were offered secondary procedures to obtain union, but only 5 (11%) accepted surgery. All of the fractures of these ten patients healed. Complications included 1 equinus contracture requiring release (after compartment syndrome) and 3 fractures that healed in >5° angulation. The average shortening of the tibia was 5 mm (0 - 15). There was one superficial and no deep infections in the group. There were no nail or screw breakages in the series. Functional results (questionnaire) were good or excellent in 38 (81%) patients. Knee pain occurred in 13 (28%) patients but resolved in all but 2 (4%). Nine patients complained of some pain in the leg, 6 had moderate restrictions (mostly in sporting activities), and 3 had significant restrictions. All three patients with a poor result had had a compartment syndrome. One required an equinus release, and the other two have pain and decreased ankle motion.

Discussion: Segmental tibia fractures are relatively uncommon and their treatment is controversial. Many are due to high-energy injury that can damage the soft tissue envelope whether open or closed. This study represents the largest prospective series of segmental fractures treated with a single technique. The series serves to remind the surgeon of the high incidence of compartment syndrome associated with segmental fractures (10%) and the longer time to union than that of simple fractures. In this series, a 100% union rate was obtained with only 11% of the patients requiring secondary procedures. There were no nail or screw breakages despite using very small diameter unreamed nails. All delayed unions occurred in open fractures or those with compartment syndrome, confirming the importance of the soft tissue envelope in the treatment of tibia fractures. Fractures without severe soft tissue injury healed without the need for secondary procedures. This was true even in a group of patients in whom secondary procedures were recommended. Few fractures had significant bone loss, and this may have contributed to the excellent union rate. The use of backtapping and the acceptance of mild shortening to obtain cortical contact and allow early weightbearing is recommended.

Conclusion: Unreamed nailing is a very effective treatment method for segmental tibia fractures. Based on our experience, secondary procedures should be considered only when there is severe soft tissue injury (compartment syndrome or grade 3B fracture). A lack of "good" callus at three months did not predict the need for secondary procedures unless there was severe soft tissue damage. Early weightbearing can be initiated if there is cortical contact even before good callus is visible without the risk of hardware failure.