Session IX - Tibia

Treatment of Tibial Fractures with the Telescopic Locking Nail

J.S. Harbers, MD; M.L.M.J. Goessens, MD; J.W.J.L. Stapert, MD, University Hospital Maastricht, The Netherlands

Introduction: During the last two decades, with the introduction of the interlocking nail, intramedullary osteosynthesis has increasingly been applied for internal fixation of tibial shaft fractures. While the interlocking nail was still in an early stage of development, other methods of fracture treatment (Sarmiento, de Bastiani) were promoted by which fractures were treated in a dynamic fashion, which was thought to promote fracture healing. Experimental studies seem to confirm that micro-movements at the fracture site and cyclic loading are beneficial for fracture healing. Following the above mentioned developments, a new intramedullary implant was designed in the early nineties, which was capable of maintaining the axis and rotation of the limb while permitting cyclic-dynamic compression at the fracture site during weightbearing. The Telescopic Locking Nail system incorporates a unique sliding component to create the possibility of dynamic locked nailing, and with simple modifications can be used as a static interlocking nail, as a device for bone-lengthening or for compression at the fracture site. We report the results of treatment of tibial shaft fractures with the Telescopic Locking Nail.

Patients and Methods: Indications for intramedullary osteosynthesis were a displaced unstable fracture of the tibial shaft or loss of reduction of a conservatively treated fracture. In seven hospitals in the Netherlands 74 patients (52 male) with a mean age of 35 years, were treated with the Telescopic Locking Nail. All fractures were classified according to the AO-classification (49% A, 39% B, 12% C). Soft tissue injury was classified according to Oestern-Tscherne for closed fractures (74%) and according to Gustillo-Anderson in case of open fractures (26%). Dynamic locking occured in 62 fractures, the remainder underwent static locking. Postoperatively no plaster casts or braces were used. Criterium for fracture union was that the fracture gap should be filled with structured callus, and not the presence of only bridging callus.

Results: Follow up data of 73 patients were available for analysis, one patient died of preexistent congestive heart failure. The mean follow up period was 12.6 months. Patients were ambulating without assistive devices after a median period of 3 weeks for closed fractures and 6 weeks for open fractures. Radiologically, closed tibial fractures healed after a median period of 18 weeks, open fractures after 22 weeks. Malunion rate was 7%, there were no rotational deformities or postoperative compartment syndroms. The infection rate for closed and open fractures was respectively 5% and 11%. The results according to the criteria of Johner and Wruhs were: excellent in 73%, good in 15%, fair in 8% and poor in 4% of the patients. Two patients needed major reinterventions (change of treatment), because of infected non-unions. Of the closed tibial fractures 98% united without further reinterventions, for open tibial fractures the primary union rate was 83%.

Conclusion: In this multicentre study the Telescopic Locking Nail has proofed to be suitable for treatment of acute fractures of the tibia. The biomechanical properties of the Telescopic Locking Nail make this implant an interesting alternative in the practice of intramedullary locked nailing. Compared to other interlocking nails it has two interesting distinctive features: dynamic interlocking without loosing rotational stability, and adaptation of the nail to any length of the tibia, which makes it very applicable in very distal fractures.