Intramedullary Nailing of Tibial Shaft Fractures: Current Concepts

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Intramedullary Nailing of Tibial Shaft Fractures
Current Concepts

• Philip Kregor M.D.
• Associate Professor
• Vanderbilt University
• Department of Orthopaedic Surgery

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Current Concepts in Tibial Nailing

• 15-20 years ago
• Open tibias - nail vs external fixator
• 10 years ago
• To ream or not to ream?
• Now - expanded indications
• Proximal, distal
• Stable Tibia fractures

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Reaming

• Preferred in closed fractures
• Earlier union
• Less malunion
• Less hardware failure
• Court Brown (1996), Finkmeier (2000), Blachut
  (1997)

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Reaming

• Open fractures - results similar reamed or
  unreamed
• Finkmeier (2000), Keating (1997)

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Reaming

• Do not ream with tourniquet up !
• Ream to fit
• Closed and most open fractures

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Tibial Nailing

• Treatment of choice most diaphyseal fractures
• Expanded indications
• Proximal / distal
• New nail designs
• Technique modification

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SPRINT Study

• 1300 patient RCT with open or closed tibia fxs-
  reamed vs unreamed
• No intervention for 6 mos (nonunion,
  dynamization)
• Closed fxs No difference in incidents
• Open fxs slightly more incidents in open fxs

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SPRINT

• Majority of incidents were broken distal screws
  (auto-dynamization)
• If Patient with patients no real difference
  in Reamed v Unreamed
• Reamed IMN more Nonunions if three strikes of
  open fxs, smoking and reamed IMN

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Tibial Shaft Fractures

• Nonoperative treatment
• Minimal soft-tissue injury
• Stable fracture
• lt 5 coronal angulation
• lt 10 sagittal angulation
• lt 5 rotation
• lt 1 cm shortening
• Ability to bear weight

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Prospective IMN vs Cast of Stable Tibia Fxs

• All stable fxs
• IMN cohort
• Increased ankle ROM at 3 mos.
• Improved SMFA at 3 mos.
• Faster return to work
• No difference at 6 months in any parameter

SEFC OTA 2008 - podium
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Tibial Shaft Fractures

• Operative treatment
• High-energy
• Significant soft-tissue injury
• Unstable
• Open
• Compartment syndrome
• Ipsilateral femoral fracture
• Inability to maintain reduction
• ? Intact fibula

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When Not to Nail the Tibia

• Articular comminution
• Deformity of medullary canal
• Dirty wound at entry portal
• Unstable patient - damage control
• Open wound, severe contamination
• Unsure surgically clean
• Surgical resources / skill
• Proximal, distal fractures

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Proximal Tibial Fractures

• Treatment options
• Nail
• Plate
• External fixation

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Proximal Metaphyseal Fractures

• Advantages of nailing
• Closed technique
• Preserves periosteal blood supply
• Low incidence of infection
• Ideal for segmental fractures
• Cosmesis, patient acceptance

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Proximal Tibial Fractures

• Problems
• Instability
• Technically demanding
• Historically high malunion rate
• Freedman Johnson 1995 - 58 gt 5
• Lang et al 1995 - 84 gt 5

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Proximal Tibial Fractures
Malunion

• Instability
• Wide metaphysis / small nail
• Valgus, anterior angulation/ translation
• Deforming forces
• Patellar tendon - extends proximal fragment
• Anterior / lateral muscles - valgus

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Proximal Tibial Fractures
Malunion

• Technique errors
• Portal placement
• Fracture reduction
• Nail design

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Technique Errors - Portal

• Tibial canal slightly lateral to center of
  plateau
• Valgus deformity
• Portal too medial
• Narrow medial metaphysis
• Nail forced laterally
• Beware external rotation
• Portal medial proximal to lateral distal
• Medial parapatellar incision
• Patellar impingement

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Technique Errors - Portal

• Anterior bow
• Portal directed too posterior
• Exit posterior fracture
• Portal too distal
• Causes posterior direction

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Technique ErrorsFracture Reduction

• Nail will not reduce fracture !
• Failure to reduce fracture before nail insertion
• Failure to account for deforming forces
• Patellar tendon extends proximal fragment with
  knee flexion - anterior bow

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Technique Errors Nail Design

• Medial to lateral screws only
• Uniplanar, nail can slide - valgus
• Oblique locking screws more stable (Henley 1993)
• One proximal screw insufficient
• Bend in nail lower than fracture
• Posterior displacement of distal fragment
• Henley (1993)

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Proximal Tibia - Solutions

• Portal placement
• Old - anterior, slightly distal to articular
  margin
• New - superior, edge of articular surface
• 9 mm lateral to midline of plateau
• Just medial to lateral tibial spine
• Safe zone (Tornetta, 1999)
• Parallel to anterior cortex

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Portal
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Proximal Tibia - Solutions

• Position - radiolucent table, leg draped free
• Incision - lateral parapatellar
• Semi-extended position (Tornetta 1996)
• Knee in 15 flexion, 2/3 medial parapatellar
  arthrotomy
• Retract patellar tendon laterally
• Reduces effect of patellar tendon
• Large exposure, need drain

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Proximal Tibia - Solutions

• Fracture reduction
• Assess behavior of proximal fragment - flexion
• Blocking screws (Krettek 1999)
• Unicortical plate (Benirschke 1995)
• Small fragment
• Temporary if open fracture
• Femoral distractor

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Fracture Reduction

• Blocking screws
• Reduce the size of the metaphysis, guide nail
• Posterior blocking screws
• Control anterior bow
• Percutaneous, medial to lateral
• Posterior to central axis
• Distal portion of proximal fragment

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Fracture Reduction

• Blocking screws
• Anterior to posterior screw
• Concave side of deformity
• Lateral screw prevents valgus
• Lateral to central axis
• Room for nail

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Fracture Reduction

• Femoral distractor
• Medial placement
• Parallel to joints
• Proximal pin may act as posterior blocking screw
• Medial external fixator

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Nail Design / Technique

• Nail with proximal bend (Henley 1993)
• Oblique locking screws (Henley 1993)
• More screws
• Fracture compression increases stability
• Insertion/locking jigs that avoid patellar
  impingement
• Lock with knee extended
• Prevents anterior bow

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Results - New Techniques

• Benirschke (1995) - variety
• 13 fractures, no malalignment
• Cole (1995) - blocking screws
• 57 proximal fourth fractures, 5 malunion
• Tornetta Collins (1996) - semi-extended
• 25 fractures, 8 malalignment
• Tornetta (2007) - AAOS - semi-extended, blocking
  screws
• 102 fractures, 6 malalignment
• Ricci (2001) - blocking screws
• 12 fractures, no malalignment
• Nork (2006) - distractor, plates, screws
• 37 proximal fourth fractures, 8 malalignment

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Distal Tibial Fractures

• Options - plate, ex-fix, nail
• Nail advantage
• Soft-tissue friendly
• Low infection rate
• Patient acceptance

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Distal Tibial Fractures

• Nailing
• Fracture reduction during insertion
• Guidewire placement perpendicular to joint
• Use blocking screws if needed
• At least 2 distal locking screws
• Additional screws for minor articular splits
• Place first
• Preop CT scan, spiral fracture
• ? Plate fibula
• Restrict weightbearing

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Distal Tibial Fractures

• Malalignment - influence of fibula
• Crates (1996)
• 12/18 (66) same-level fibula
• 1/11 different-level fibula
• 0/7 intact fibula
• 4/8 single screw
• Recommended fixing same-level fibula

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Distal Tibial Fractures

• Fibular plating
• Egol et al (2006) - loss of reduction
• 1/25 (4) fibular plating
• 6/47 (13) not plated

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New Nail Designs

• Locking screws close to tip
• More locking screws
• Different planes
• AP screw not percutaneous
• Avoid tendons, neurovascular
• Locking locking screws

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Anterior Knee Pain

• Katsoulis et al. 2006 - meta-analysis
• Mean incidence 47.4 (10-86)
• Cartwright, Terry 2006
• 83 injured leg, 40 uninjured leg
• Vaisto et al 2007
• Related to quad strength
• Resolves in some in 3-8 years

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Anterior Knee Pain

• Multifactorial
• Nail prominence
• Patellar tendon
• Fat pad
• Chondromalacia patella
• Infra-patellar saphenous nerve
• Intra-articular damage
• Pre-existing

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Anterior Knee Pain

• Recommendations - reduce not eliminate
• Check screw length
• Use soft-tissue protectors
• Countersink nail
• Flex knee gt100
• Consider small, horizontal incision
• Nail removal helps about 50
• May cause if asymptomatic

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Bone Morphogenic Protein

• BMP-2 (Infuse)
• Bovine collagen sponge
• Recombinant human BMP-2
• Indications
• Open tibial fracture
• IM nail
• Within 14 days of injury

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Bone Morphogenic Protein

• Contraindications
• Pregnancy
• Skeletal immaturity
• Infection
• Tumor/history of cancer
• Allergy

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Bone Morphogenic Protein

• Precautions - not studied
• Nursing mothers
• Liver or kidney problems
• Metabolic bone disease
• Autoimmune / immune deficiency
• Multiple use

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BMP-2 Results

• JBJS 2002
• 421 patients - prospective, randomized
• 1.50mg/ml BMP-2
• 44 decreased risk of delayed union intervention
• Faster union
• Fewer hardware failures
• Fewer infections in type 3 fractures (24 vs 44)

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