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Intramedullary Nail Fixation of Distal Tibia Fractures: Tips and Tricks

Talerico, Michael MD; Ahn, Jaimo MD, PhD, FACS

Journal of Orthopaedic Trauma: November 2016 - Volume 30 - Issue - p S7–S11
doi: 10.1097/BOT.0000000000000693
Supplement Article
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Summary: The objective of this article is to highlight the salient points of preoperative planning, intraoperative considerations for fracture reduction methods, and implant fixation when treating distal diaphyseal or diametaphyseal tibia fractures with an intramedullary nail. Through review of the necessary preoperative considerations, techniques available to hold and maintain a reduction, and lastly how to maximize the selected implant of intramedullary nail, we hope to assist the treating surgeon in simplifying these sometimes complex fractures into manageable injuries that can be treated successfully with an intramedullary implant.

*Department of Orthopaedic Surgery, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA; and

Orthopaedic Trauma and Fracture Service, Department of Orthopaedic Surgery, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA.

Reprints: Jaimo Ahn, MD, PhD, FACS, Orthopaedic Trauma and Fracture Service, Department of Orthopaedic Surgery, Penn Presbyterian Medical Center, University of Pennsylvania, 3737 Market St, Room 6121, Philadelphia, PA 19104 (e-mail: jaimo.ahn@uphs.upenn.edu).

J. Ahn is an Associate Editor of Journal of Orthopaedic Trauma. The remaining author reports no conflict of interest.

Accepted August 15, 2016

The surgical management of distal tibia diaphyseal fractures (OTA Classification Type 42A, 42B, and 42C) and distal metaphyseal tibia fractures with or without intraarticular extension (OTA Classification Type 43A, 43B1 or 43B2, and 43C1 or 43C2) with an intramedullary implant can be successfully performed with the utilization of appropriate aids and proper techniques.1 The use of selected adjuncts can allow for efficient and appropriate fracture reduction and stable fixation. The potential challenges stem from the fact that these fractures are metaphyseal and at the end of the limb. This article will provide an understanding of how to overcome the above-mentioned difficulties through an emphasis on selected techniques and injury-specific tips.

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THE SELECTION OF THE APPROPRIATE IMPLANT FOR FRACTURE FIXATION IS THE FIRST STEP IN THE MANAGEMENT OF THESE INJURIES

Use of an intramedullary implant protects the extraosseous blood supply, allows load-sharing, and minimizes extensive soft tissue dissection.2 Biomechanically, an intramedullary implant has been shown to be superior in axial loading stress, whereas being equivocal under torsional loads compared with a medial plate construct, thus perhaps permitting earlier weight-bearing.3 However, evidence suggests that while rates of infection, nonunion, and secondary procedures are similar between intramedullary nailing and plate fixation for distal tibia fractures, there is an increased rate of malalignment with the use of intramedullary nail.4 The use of an intramedullary implant is advised in patients with distal tibia injury patterns as they result in decreased soft tissue dissection, and possibly allow earlier weight-bearing.

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PERFORM A COMPLETE AND DETAILED PREOPERATIVE PLAN

A proper plan includes patient characteristics, timing of surgery, standard instruments and implants, patient positioning, radiographic positioning and plan to obtain necessary imaging, surgical approach, reduction technique (including special adjuncts), and plan for definitive fixation.5 In the case that there are unforeseen intraoperative events that complicate the use of an intramedullary nail, a secondary definitive implant should be part of the preoperative plan. Our recommendation is to have a plating system (independent of reduction-fixation adjunct) immediately available for use.

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HARD TO TELL WHAT THE RIGHT REDUCTION IS, LET ALONE OBTAIN IT

Metadiaphyseal regions each have their own slopes and merely making the tibia “straight” with simple traction does not always result in the correct reduction. Here are a few tips to help you succeed:

  • The goal of the operation is to restore length, alignment, and rotation of the affected lower extremity through fracture reduction and fixation. The more distal the fracture and the greater the comminution, the more difficult it is to know what the end reduction goal is and when it has been achieved—especially with small field-of-view fluoroscopy. Therefore, if there is uncertainty regarding final reduction goals, we recommend obtaining perfect AP and lateral images of the contralateral limb. If length assessment is an issue, this can be performed in the operating room as well. Clinical assessment of limb length can be performed before sterile draping of the operative leg or by draping in both legs for intraoperative comparison. Radiographic assessment of osseous length and alignment may be obtained by intraoperatively using full-length plain films of the tibia. Finally, overall limb alignment may be assessed intraoperatively using fluoroscopy and a radioopaque object (eg, ruler or bovie cord) in the supine patient.6
  • Simplify the obtainment of fluoroscopic imaging for the surgical team and for the radiology technician. Use a table that is free at the foot end so that the surgical team has easy access to the limb from distal end of the bed. Also consider using a semi-extended approach which will allow the fluoroscopist to come in from the contralateral side of the operating table with standard AP and cross-table lateral views and which will allow the surgeon to stand at the end of the table for unstrained manipulation of the fracture site or associated instrumentation.7
  • Minimize potential areas of fatigue for the surgical team during the case. Through the use of the universal distractor, gross correction and length can be obtained without the required constant force applied by a member of the surgical team. The best control of the fracture is obtained when the Schanz screws of the universal distractor are placed in the proximal tibial physeal scar and the distal tibial physeal scar. Ensure that the proximal pin for the distractor is mid-sagittal to slightly posterior (on the lateral image) as to prevent interference with the entry site for the intramedullary nail; and as distal as possible so as to not block the distal path of the nail. It is important to maximize the distal position of the nail with distal injuries. Keep the pins parallel to the joint on AP for easy reference and place the distractor bar posterior and out of the way of lateral imaging.8,9 Alternatively, a temporary intraoperative external fixation construct with proximal and distal tibia transfixion pins connected in a rectangular construct may be placed to aid in your reduction, applying the same principles listed above to prevent interference with the intramedullary nail path.10,11
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USE APPROPRIATE ADJUNCTS TO GET YOUR REDUCTION

Good positioning and traction alone would not reliably reduce the fracture deformity, so consider these adjuncts.

  • For placing the guide wire, take care to precisely position the wire in the distal segment. Many systems have instrumentation to help with guide wire trajectory; alternatively a guide wire with a bent tip can be used. The understanding that the lateral cortex is a more reliable “flat” radiographic marker and that the center of the shaft aligns slightly lateral to the center of the plafond on an AP view are important to correct guide wire placement.12,13
  • If indirect manipulation is not working, then consider using some of the following adjuncts:
    • ○ Percutaneous clamp placement: A percutaneously applied point-to-point clamp can be extremely useful in closed injuries, particularly for spiral or oblique fracture patterns (Fig. 1).14 Minimize incisions using fluoroscopy to localize for exact placement of the tines into the appropriate cortex to provide interfragmentary compression. It is critical to use atraumatic soft tissue technique as the clamps must remain in place until the intramedullary nail interlocks are in place, so wide clamps or even periarticular clamps may be necessary depending on body habitus.
    • ○ Unicortical plate: This will typically require a direct open reduction when used to help achieve reduction. If a plate is required to help overcome a deforming force, it should be a rigid plate (either small fragment “recon” style or compression plates are adequate); flexible mini-fragment plates or “tubular” plates are often not sufficient at maintaining reduction. Although using nonlocking screws can help with the reduction and pull the plate flush to bone, they can sometimes be too long when the plate cannot be positioned anteriorly or posteriorly to avoid the intramedullary canal; therefore, unicortical locking screws may be needed to allow passage of the nail.15 In the setting of open fractures, consider using the existing soft tissue exposure provided by the injury, and extend the open wound as needed to debride and place a unicortical plate to aid in the reduction (and possibly act as a cortical replacing plate in injuries with severe bone loss/comminution).16 These unicortical plates are to remain in place until the nail is locked proximally and distally, minimizing the risk of reduction loss. Finally, it should be noted that unstable fractures will displace with improper contouring of the plate as the plate will be stronger and more rigid than the bone.
    • ○ Blocking wires and screws: Blocking screws can be placed at multiple points—before guide wire placement as well as during reaming and nail insertion. They can be used to recreate deficient cortices and narrow the effective medullary canal available for the nail, thus aiding in correction of translation and angulation to allow for the correct passage of a guide wire and implant (Fig. 2).9,17–19 In biomechanical studies, blocking screws have demonstrated the ability to increase resistance to deformity in the distal metaphyseal tibia.20 When considering blocking screws, the surgeon can use large fragment screws, or standard interlocking blots from the nail set (off-label use).
    • ○ The use of permanent screws versus temporary blocking Steinmann pins or Kirschner wires can be dictated by fracture pattern, patient bone quality, and surgeon choice. If the surgeon selects pins/wires, they must be of adequate diameter to withstand reaming and the forces of nail insertion. It is recommended that the selected pin or wire be greater than 2 mm in diameter when being utilized for these purposes. After the nail construct is locked, the pins/wires may be replaced at the conclusion of the case with the appropriate sized screws.21
    • ○ If a single percutaneous wire is inadequate to help redirect the nail, a series of cascading wires can assist in properly directing the instruments and implant down the correct path.
    • ○ Intraoperatively, the surgeon should be vigilant for intraoperative fracture propagation or comminution when using blocking screws, especially in setting of a ballistic mechanism such as a gunshot injury, or in osteopenic bone.
    • ○ Consider fibular fixation: Fixation of the fibula, especially of lateral malleolus fractures that would necessitate fixation even independent of the tibia fracture, can aid you in obtaining and maintaining tibial alignment intraoperatively and until union.
FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

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MAINTENANCE OF REDUCTION UNTIL UNION

Now that the fracture is reduced, definitive fixation must be applied and maintained throughout the patient's time to osseous union. Techniques to improve the definitive intramedullary fixation are as follows:

  • Know the selected intramedullary implant and the available distal fixation options. As a general rule, at least 2 points of direct nail fixation will be needed distally. Some nails allow for the placement of as many as 4 screws in multiple angles (which will increase multiaxial stability), assuming there is enough distal bone for them to engage. It has been shown that the addition of a third bicortical interlocking screw improves the stiffness of the construct in comparison to a construct with 2 distal bicortical interlocking screws with or without the use of a distal blocking screw.22
  • Some intramedullary nails may also allow for screw options that engage the nail through threads nearly eliminating screw nail toggle, creating an angle-stable locked construct. Biomechanical cadaveric studies have shown that using 2 parallel angle-stable locking screws provides higher torsional stiffness, and less torsional deformation than a conventionally locked construct with 3 conventional distal interlocking screws, as well as reduced inter-fragmentary movement at the fracture site, and construct stiffness not dependent on the bone mineral density.23,24
  • Similar to external fixation principles, larger screws (some nails use smaller screws for smaller diameter nails), more screws, out of plane screws, and separation in the bone segment (near-far) will optimize fixation of the nail.
  • In certain cases, the desired distal end point of the nail is extremely distal. In such cases, a bend in the ball-tipped guide wire may prevent reaming to the distal most end of the bone. If that depth of reaming is required, consider using a guide wire that has not been bent. Alternatively, some surgeons do not ream the distal segment at all to allow for better nail stability in the metaphyseal bone.
  • Unless there is a clear reason to remove blocking screws (eg, in the way) or unicortical plates (eg, impinging on soft tissues), implant adjuncts should remain if they were needed to aid in achieving or maintaining reduction in the first place.
  • If after final nail and interlocking screw placement, the intramedullary fixation is not deemed adequate, or it is felt that additional fixation would help accelerate weight-bearing and functional recovery for the patient; consider using percutaneous subfascial plate placement or “miss-a-nail” screws to provide a neo-metal cortex to the nail.
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DO NOT MISS THE “OTHER” FRACTURE

Up to a third of distal third tibial fractures have an associated intraarticular component, either as an extension of the primary fracture line or as a distinct plafond segment.25–27 Distal third tibial shaft fracture location, spiral type fracture pattern, or an associated spiral fibula fracture is predictive of an intraarticular component.28 Because of this, we recommend a CT through the ankle joint in addition to careful oblique imaging with intraoperative fluoroscopy. If such an injury is found, we recommend independent management of the intraarticular segment before nailing of the shaft component.29,30

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CONCLUSIONS

Treatment of distal tibia fractures with an intramedullary implant can be complex and challenging, but it does not have to be stressful or difficult. Careful preoperative evaluation and meticulous tactical planning will allow the surgeon to enter the operating room ready to execute the plan. Simplify the case by having the knee in a semi-extended position for easier imaging and access, through use of existing external fixators or universal distractors, and by being able to deftly select from a variety of reduction methods including the utilization of blocking screws and unicortical plate fixation. Lastly, it is important to fully use the selected intramedullary nail and available distal bone to obtain multiple points of fixation.

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ACKNOWLEDGMENTS

The authors acknowledge Samir Mehta, MD, Department of Orthopaedic Surgery, University of Pennsylvania for providing clinical radiograph for figures.

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Keywords:

distal tibia fracture; intramedullary nail; blocking screw; universal distractor

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