The goal of management of a distal metaphyseal tibial fracture is to provide stable fixation with minimal additional soft-tissue injury. Individual case variables, including the extent of soft-tissue injury, should influence the ultimate treatment decision.
Cast treatment of tibial fractures requires prolonged immobilization, which is associated with subsequent decreased ankle motion1-3. Maintaining reduction in a cast is difficult and requires frequent office visits, radiographs, and adjustments. External fixation may lead to diminished ankle motion4. Small wire fixators allow early ankle joint mobility, but this treatment method is complicated by pin-track infections, septic arthritis, malalignment, and delayed unions5,6. Open reduction and internal fixation provides stability, but it often requires extensive soft-tissue dissection and further devascularization of the underlying tibia7,8. In addition, the subcutaneous location of plates may lead to symptomatic hardware requiring removal. Newer techniques of minimally invasive submuscular and subcutaneous plate fixation can address several of these issues, and predictable healing and a low rate of soft-tissue complications have been reported9,10.
Although intramedullary nailing is accepted as a method for stabilizing diaphyseal tibial fractures11-22, its role in the treatment of distal metaphyseal fractures has not been well defined23-26. Fixation with intramedullary devices is a technique that is already familiar to most surgeons. It spares the extra-osseous blood supply, allows load-sharing, and avoids extensive soft-tissue dissection. Recent changes in intramedullary nail design have extended the spectrum of fractures amenable to this type of fixation. Concerns regarding difficulties with reduction, distal propagation of the fracture, hardware failure, and inadequate distal fixation leading to malalignment have slowed the acceptance of intramedullary nailing as a treatment for distal metaphyseal fractures.
The purpose of this study was to evaluate reamed intramedullary nailing of distal metaphyseal tibial fractures located within 5 cm of the ankle joint.
Materials and Methods
During a sixteen-month period at two institutions, 243 skeletally mature patients with a tibial fracture were treated with intramedullary nailing. Biplanar injury radiographs were evaluated to determine the fracture location and involvement of the distal part of the tibia. Inclusion criteria for this retrospective review were skeletal maturity, a fracture involving the distal 5 cm of the tibia, and treatment with an intramedullary nail of a fracture pattern that allowed placement of at least two interlocking screws through the nail. No blocking screws were used. Of the 243 operatively treated fractures, thirty-six (14.8%) met the inclusion criteria. Ten of these fractures had a simple articular extension. Injuries that primarily involved axial loading of the ankle joint with substantial articular displacement were not considered to be amenable to nailing and were not included in the study. Seven orthopaedic traumatologists who were experienced with intramedullary fixation treated these patients.
There were twenty-four male and twelve female patients ranging in age from eighteen to eighty-two years (mean, thirty years). The various mechanisms of injury included a fall from a height (thirteen patients), a sports-related injury (seven), a motor-vehicle accident (six), a motorcycle accident (five), an automobile-pedestrian accident (three), an explosion (one), and a crush injury (one). The average Injury Severity Score (ISS)27 was 12.8 points (range, 9 to 43 points). According to the AO/OTA28 guidelines, there were eight 43A1, five 43A2, thirteen 43A3, six 43C1, two 43C2, and two 43C3 fractures. Fourteen fractures (39%) were open: one was classified29 as type I; two, as type II; ten, as type IIIA; and one, as type IIIB. An associated fracture of the fibula was present in thirty-five patients. Four patients had a concomitant leg compartmental syndrome, and each was treated with compartment fasciotomy. Fourteen patients (39%) had an additional extremity fracture: six had an ipsilateral lower-extremity fracture; five, a contralateral lower-extremity fracture; and three, an upper-extremity fracture. The ipsilateral lower-extremity injuries included multiple foot fractures in two patients, a tarsometatarsal fracture-dislocation in two, a tibial plateau fracture in one, and a femoral fracture in one.
The patients with distal articular extension of the tibial fracture underwent preoperative computed tomography scanning of the ankle to further define the fracture and aid in treatment planning. The ten 43C fractures (28%) with articular extension were treated with supplementary percutaneous fixation prior to the intramedullary nailing (Figs. 1-A and 1-B, 1-C, 1-D, 1-E, 1-F and 1-G).
The tibial fractures were treated with a reamed intramedullary nailing system that increases distal fixation with up to three biplanar distal interlocking screws passing through the distal 3 to 4 cm of the nail. In six patients in whom immediate intramedullary nailing was not feasible, temporary ankle-spanning external fixation was used to allow resolution of the soft-tissue swelling, additional radiographic evaluations, secondary irrigation and débridement, or medical stabilization of the patient.
A fibular plate was used as a primary reduction aid to obtain length, alignment, and rotation of the distal tibial segment in nineteen patients (53%). Additional techniques for obtaining and maintaining the distal metaphyseal reduction during all aspects of the nailing included the use of a femoral distractor, temporary fixation with a percutaneous clamp, percutaneous manipulation with Schanz pins, and open reduction and temporary fixation with a unicortical tibial plate. Critical surgical tenets included the central placement of the guide wire and all reamers and maintenance of the reduction at the time of nail passage.
Biplanar radiographs were made for all patients until fracture-healing occurred. Fracture union was defined as radiographic evidence of bridging cortical bone on at least three cortices combined with the patient's ability to bear full weight on the extremity. Radiographic measurements were performed by the two senior authors (S.E.N. and A.K.S.), who came to a consensus regarding the final values. Radiographic measurements included the distance between the tip of the nail and the distal tibial articular surface on the lateral view, the distal extent of the fracture on the anteroposterior and lateral views, and alignment on the anteroposterior and lateral views. Malalignment was defined as ≥5° of angulation in any plane. Each patient's series of radiographs was reviewed to assess differences in length and alignment between the immediate postoperative and final radiographs.
The patients included in the study followed the same postoperative protocol. The leg was initially placed in a splint for forty-eight to seventy-two hours. A removable boot was then applied, if the patient was thought to be able to comply with the postoperative protocol. Patients who were thought to be unable to follow postoperative instructions wore a short leg cast for the initial six weeks. Patients with an extra-articular fracture were not allowed to bear weight for six weeks, and those with articular extension of the fracture were not allowed to bear weight for twelve weeks. Three patients with bone loss underwent a staged bone-grafting procedure, and weight-bearing was delayed for an additional six weeks after that procedure. All patients who were compliant with postoperative instructions were encouraged to begin an early active range of motion of the ankle.
To evaluate the functional outcome and health status of this group of patients, we administered the Short Form-36 (SF-36)30,31, a generic health status measure, and the Musculoskeletal Function Assessment (MFA)32-34, a functional outcomes measure. The reliability, validity, and responsiveness of both measures have been documented. The functional outcome assessments were performed at a minimum of one year and at a minimum of two years after the injury. Patients were contacted by an independent, trained medical interviewer who was not involved in their treatment. The questionnaires were completed either during a telephone interview or during a scheduled visit to the clinic.
The SF-36 (version 1) was administered to compare our patient population with the United States population norms. The SF-36 is divided into eight components: physical functioning, role limitations due to physical health problems, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems, and mental health. Each component is given a score ranging from 0 to 100 points, with high scores indicating better function.
The MFA allows comparison of the study population with published population normative values and with patients with isolated lower-extremity trauma33. The MFA has ten categories: mobility, hand and fine motor function, housework, self-care, sleep and rest, leisure and recreation, family relationships, cognition and thinking, emotional adjustment and adaptation, and employment. Each category is scored independently, and an overall score can be calculated. Values range from 0 to 100 points, with low scores indicating better function.
A paired t test was used to compare the alignments on the postoperative and final radiographs. A Fisher exact test was used to evaluate the difference in the fracture pattern and the immediate postoperative alignment between the patients who were included in the study and those who were lost to follow-up. A group t test was used to assess differences in the time to fracture-healing and all outcome data. A correlation coefficient was calculated to determine if patient and injury variables were associated with functional outcomes. A p value of <0.05 was considered to indicate a significant difference.
The average distance from the distal extent of the tibial fracture to the plafond was 35 mm (range, 0 to 45 mm). The average distance between the distal tip of the nail and the articular surface of the plafond was 6.2 mm (range, 2 to 10 mm). Three distal interlocking screws were used in twenty-three patients, and two distal interlocking screws were used in thirteen. The average sagittal plane deformity was 0.9° (range, 0° to 5°). The average coronal plane deformity was 0.3° (range, 0° to 5°). Acceptable alignment was obtained in thirty-three patients (92%). Two patients had a 5° recurvatum deformity, and one patient had a 5° valgus deformity. One patient had 5 mm of shortening.
Of the thirty-six patients in our study, five were lost to follow-up and one died from pulmonary complications on the third postoperative day. The remaining thirty patients had radiographic evidence of healing at the time of follow-up and no change in the final alignment in either the coronal or the sagittal plane compared with the alignment on the immediate postoperative radiographs (p = 0.9). Of the six patients who were lost to follow-up, two had an intra-articular fracture and four had an extra-articular fracture. The fracture patterns and immediate postoperative alignment in these patients were not significantly different from those in the remaining thirty patients (p = 0.74).
Additional surgical procedures (bone-grafting or dynamization by removal of the static proximal interlocking screw) to promote union were performed, at the discretion of the surgeon, in seven patients (19%). Three patients with an open fracture and associated bone loss underwent a staged iliac crest autograft procedure at an average of 6.7 weeks (range, six to eight weeks) after the injury. No bone-grafting procedures were required to obtain union in any patient with a closed fracture. Four patients underwent dynamization of the nail at three months postoperatively, to encourage healing. This allowed up to 1 cm of shortening, with proximal nail migration in a proximal slotted hole. All thirty patients had fracture union, at an average of 23.5 weeks (range, thirteen to fifty-seven weeks) from the date of the intramedullary nailing. The average time to fracture-healing was significantly longer for the three patients with associated bone loss requiring a staged autografting procedure (average, 44.3 weeks; range, thirty-three to fifty-seven weeks) than it was for the remaining twenty-seven patients (average, 21.2 weeks; range, thirteen to fifty-five weeks) (p = 0.009).
Complications included one deep infection at the site of an open fibular fracture and one iatrogenic proximal tibial fracture that occurred during intramedullary nailing. The infection responded to local débridement and intravenous administration of antibiotics. The iatrogenic proximal tibial fracture remained well aligned after passage of the intramedullary nail and went on to heal uneventfully.
Evaluations with the SF-36 and the MFA were carried out at a minimum of one year (average, 1.2 years; range, 0.9 to 1.6 years) following the injury for nineteen patients (53%) and at a minimum of two years (average, 4.5 years; range, 2.2 to 6.0 years) for fifteen patients (42%). A subset of eleven patients was evaluated at both a minimum of one year and a minimum of two years and thus could be assessed to determine the time-dependent changes in function according to the MFA. Of the original thirty-six patients, three had died, three declined to participate in the study, and fifteen could not be located.
The scores for the eight subsections of the SF-36 determined at the final evaluations of the study patients were compared with previously reported normative values for the general population35 (see Appendix). At the evaluations performed at a minimum of one year, the values for the patients did not differ significantly from the normative data in five of the eight categories (general health, vitality, social functioning, role limitation emotional, and mental health) and showed significantly worse function in three categories (physical function [p = 0.0005], role limitation physical [p = 0.0001], and bodily pain [p = 0.005]). At an average of 4.3 years after the injury, the final SF-36 scores in seven of the subsections did not differ significantly from the normative values and the score in one subsection (physical function) showed significantly worse function (p = 0.03). Only the score for bodily pain showed a significant improvement between the evaluation performed at a minimum of one year and that performed at a minimum of two years (p = 0.02).
At the evaluations performed at a minimum of two years, the average MFA score (and standard deviation) for the fifteen patients was 16.7 ± 15.6 points (range, 0.6 to 41.6 points), which indicated better overall function than that shown by previously published total MFA dysfunction scores for patients assessed one year after an isolated knee, leg, or ankle injury (average score, 22.9 ± 18 points; range, 2 to 59 points; p = 0.18)33. The average MFA dysfunction score determined at a minimum of two years in our study was better (lower) than that calculated at a minimum of one year (26.1 points; p = 0.07) for the nineteen patients evaluated at that time; this indicated that there was continued recovery and functional improvement with time. The total MFA dysfunction score for the general population averages 9.3 points (range, 0 to 59 points)33.
Compared with previously reported values for patients without lower-extremity injury (normative values), the patients in our study who were assessed at a minimum of one year demonstrated no significant difference in five of the ten subsections (fine motor, sleep and rest, family relationships, emotional adjustments, and employment) and had significantly worse function in five categories (mobility [p = 0.0001], housework [p = 0.02], self-care [p = 0.02], leisure and recreation [p = 0.01], and cognition and thinking [p = 0.002]) (see Appendix). The patients evaluated at a minimum of two years demonstrated no significant difference in any category compared with previously reported values for patients evaluated at one year after an isolated lower-extremity injury36, and they also had no significant difference compared with normative values (see Appendix).
Of the several patient and injury variables that were assessed to evaluate their influence on functional outcomes as determined with the MFA, only an open fracture was found to be associated with poorer function (p = 0.002). An associated lower-extremity fracture, intra-articular extension, bone loss requiring bone-grafting, and time to union were not found to be associated with poorer function.
Intramedullary nailing of open and closed tibial shaft fractures has been associated with high rates of radiographic and clinical success11-22, but the use of this procedure has not become widely accepted for distal metaphyseal fractures23-26. While external fixation has been used successfully to treat open distal tibial fractures, intramedullary nailing has been associated with a decreased number of secondary surgical procedures to achieve healing and better maintenance of limb alignment37-39. Because fractures distal to the tibial diaphysis and within 5 cm of the ankle joint may represent a different injury, they have been excluded from reports on intramedullary nailing of tibial shaft fractures18,38. The distal segment of these fractures is more difficult to control with intramedullary implants because of the metaphyseal flare above the plafond. In addition, the poorer soft-tissue coverage in this region is associated with wound complications. The proximity to the ankle joint may amplify the bending moment of the short distal segment and may allow fracture propagation into the ankle joint. Percutaneous plate osteosynthesis is an excellent alternative for the treatment of these distal fractures as it allows reduction and stable fixation of short distal metaphyseal segments, facilitating predictable healing9,10. However, intramedullary nailing may offer fixation advantages for patterns involving noncontiguous proximal tibial fractures or proximal extension of the fracture. While tibial nailing may simultaneously address proximal fracture extension, noncontiguous fractures, and distal fractures, anterior knee pain remains a problem; it has been previously reported in the majority of patients, regardless of the surgical approach relative to the infra-patellar tendon40-42.
Intramedullary nailing of distal tibial fractures has been previously described23-26. Similarly, tibial fractures with associated ankle fracture and articular extension have been treated successfully with intramedullary nailing23,25. One difficulty in selecting candidates for intramedullary fixation of a distal tibial fracture is differentiating tibial fractures with simple articular extension from axial loading injuries with primary articular involvement. In our study, patient selection was based on the primary fracture being located in the metaphysis, with or without simple articular extension. Injuries that primarily involved axial loading of the ankle joint with substantial articular displacement were not considered to be amenable to intramedullary nailing.
Unreamed tibial nailing has been used for distal metaphyseal fractures, including those with articular extension24. Although, in one study, 42% of patients required a second surgical procedure to obtain union, alignment was well maintained24. In the largest series of distal metaphyseal fractures treated with locked intramedullary nailing of which we are aware, Robinson et al. reported a 100% union rate25. Their series included both extra-articular tibial fractures and tibial fractures with extension into the ankle joint. Supplementary fixation of the articular extension was performed after the intramedullary nailing. Despite modifying the nail to allow placement of a minimum of two distal locking screws, maintaining the reduction was difficult. This resulted in varus and recurvatum deformities of >10°. In addition, fatigue failure of the nail has been reported within the first year after reamed nailing of distal tibial fractures43. Particular caution is necessary when treating fractures within 7 cm of the ankle joint43.
Difficulty with reduction of distal metaphyseal tibial fractures may be related to the large diameter of the distal part of the tibia relative to the diameter of the intramedullary nail; the interface between the cortex of the tibia and the nail cannot be used to assist in fracture reduction. To address this, some researchers have advocated the use of adjunctive blocking screws to obtain and maintain the reduction and alignment44, and the superior biomechanical strength of these constructs has been demonstrated45. These screws were not used in our series because the patients were treated with alternative reduction methods, including plate fixation of the fibula prior to intramedullary nailing24, temporary reduction of the tibia with a unicortical plate in patients with an open injury, reduction with a percutaneous clamp25, and placement of a femoral distractor. One of our surgical goals was to obtain accurate alignment prior to placement of the medullary implant, obviating the need for supplemental fixation techniques. Following placement of the nail, the ability to interlock distally with multiple screws in two planes probably helped to maintain the reduction.
In our series, articular extension was addressed prior to intramedullary nailing of the tibia24 to prevent additional displacement and to assist in the reduction of the distal fragment. In no case did nail insertion lead to loss of reduction of the articular segment. Strategic placement of periarticular lag screws allowing adequate space for insertion of the medullary nail limits the potential for secondary articular displacement.
Secondary procedures were performed prophylactically to obtain union in selected patients: early dynamization of the nail was done in four patients, and bone-grafting was performed in three patients who had substantial bone loss. Despite the early autografting, the three fractures with associated bone loss required significantly more time to unite (p = 0.009). For dynamization, we routinely removed a proximal interlocking bolt, allowing proximal migration of the nail for compression. In this way, the relationship between the implant and the short distal tibial segment is maintained and distal migration of the nail with joint penetration can be avoided.
The outcome data demonstrated that, at a minimum of one year after the injury, patients continued to have significant limitations in several domains, but they had continuing improvement for up to two years after the operation. The SF-36 data are difficult to interpret because reference data for patients with musculoskeletal injury are unavailable. Despite the stratification of normative data into age and gender-matched values31, the small number of patients in our series additionally limited the utility of the SF-36 data. However, at a minimum of two years after the injury, our patients did demonstrate function that was similar to population normative values, with the function actually better in the general health category. The one-year MFA dysfunction scores for our patients closely approximated the published values for patients evaluated one year after an isolated knee, leg, or ankle injury33. However, at a minimum of two years, our patients demonstrated better overall musculoskeletal function compared with the one-year values. Compared with an uninjured population36, our patients who were evaluated at a minimum of two years (average, 4.5 years) demonstrated a score that was worse (indicating increased dysfunction) by more than one standard deviation in only two of the ten MFA domains. The presence of multiple other fractures and organ-system injuries may have contributed to the poorer overall functional results in our patients. The significant functional improvement between the one and two-year evaluations demonstrated by the MFA was observed in only one of the eight categories within the SF-36. This suggests that the MFA may be a more sensitive tool for following the functional outcomes in these patients over time.
Limitations in this study include its retrospective design, the small number of patients, the fact that multiple surgeons participated in the treatment, and the nonstandardized radiographic assessments. Furthermore, the ability to differentiate which fractures are appropriate for intramedullary nailing is largely qualitative and based on experience and an understanding of the fracture pattern, especially with regard to fractures with articular extension (classified as AO/OTA 43C). In addition, the SF-36 scoring may not provide meaningful information: for example, knowing that a patient's role physical function score is 72 of 100 points is not useful for the patient or the physician. While the categories in the MFA are clearer and easier for the patient and physician to understand, this instrument has yet to achieve the widespread popularity of the SF-36 and it does not have a large pool of reference norms for various diseases.
We concluded that intramedullary nailing is a safe and effective technique for the treatment of distal metaphyseal tibial fractures. It avoids the additional soft-tissue dissection associated with traditional open procedures as well as the complications associated with external fixators. Newer nail designs allow the distal segment to be controlled through placement of multiple distal interlocking screws within a small distance above the tibial plafond. Alignment can be well maintained despite the short distal tibial segment, and a simple articular fracture or fracture extension is not a contraindication to intramedullary fixation.
Tables presenting detailed outcome data derived with the SF-36 and the MFA are available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on “Supplementary Material”) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ▪
Investigation performed at the Harborview and Swedish Medical Centers, Seattle, Washington
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. R.A. Winquist received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Zimmer). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
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