Factors Influencing Functional Outcomes After Distal Tibia Shaft Fractures

Department of Orthopaedic Surgery, MetroHealth Medical Center, affiliated with Case Western Reserve University School of Medicine, Cleveland, OH, USA.
Journal of orthopaedic trauma (Impact Factor: 1.8). 12/2011; 26(3):178-83. DOI: 10.1097/BOT.0b013e31823924df
Source: PubMed


Surgical treatment of displaced distal tibia fractures yields reliable results with either plate or nail fixation. Comparative studies suggest more malalignment and nonunions with nails. Some studies have reported knee pain after tibial nailing. However, plates may be associated with soft tissue complications, such as infections or wound-healing problems. The purpose of this study was to assess functional outcomes after distal tibia shaft fractures treated with a plate or a nail. We hypothesized that tibial nails would be associated with more knee pain and that plates would be associated with pain from implant prominence, each of which would adversely affect functional outcome scores.
Randomized prospective study.
Level 1 trauma center.
One hundred four patients with extra-articular distal tibia shaft fractures (OTA 42), mean age of 38 years (range, 18-95), and mean Injury Severity Score of 14.3 (range, 9-50).
Patients were randomized to treatment with a reamed intramedullary nail (n = 56) or standard large fragment medial plate (n = 48).
Ability to work was evaluated after a minimum of 12 months, with mean of 22 months. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were completed.
Mean MFA was 27.5, and mean total FFI was 0.26; P < 0.0001 versus an uninjured reference population. Sixty-one of 64 patients (95%) employed at the time of injury had returned to work, although 31% had modified their work duties because of injury. Three patients were unable to find work. None reported unemployment secondary to their tibial fracture. Forty percent of all patients described some persistent ankle pain, and 31% had knee pain after nailing, versus 32% and 22%, respectively after plating. Both knee and ankle pain were present in 27% with nails and 15% with plates (P = 0.08), and rates of implant removal were similar after nails versus plates. Patients with malunion ≥5 degrees were more likely to report knee or ankle pain (36% vs 20%, P < 0.05). Except 1 patient with knee pain when kneeling, none reported modifying activity because of persistent knee or ankle pain, although knee and ankle pain were more frequent in the unemployed (P = 0.03). Unemployed patients requested implant removal more frequently (24% vs 9.2%, P = 0.07) and continued to report pain afterward. Although FFI and MFA scores were not related to plate or nail fixation, open fracture, fracture pattern, multiple injuries, Injury Severity Score, or age, both MFA and FFI scores were worse when knee pain or ankle pain was present (all Ps < 0.004) and in patients who remained unemployed (P < 0.0001). All 4 patients with work-related injuries had returned to employment but had worse FFI scores (P = 0.01).
Mean MFA and FFI scores suggest substantial residual dysfunction after distal tibia fractures when compared with an uninjured population. Mild ankle or knee pain was reported frequently after plate or nail fixation but was not limiting to activity in most. Angular malunion was associated with both knee and ankle pain, and there was a trend toward more patients with knee and ankle pain after tibial nailing. No patients reported unemployment because of their tibia fracture, but unemployed people described knee and ankle pain more frequently and had the worst functional outcome scores.

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    • "Until date, the etiology of anterior knee pain after intramedullary nailing of tibia is still unknown. Several studies have proposed that a patellar splitting approach for nail insertion is associated with a higher prevalence of anterior knee pain than a medial paratendinous approach.[67891011] Some other studies have reported technical causes for the chronic anterior knee pain such as nail or screw prominence, traumatization of the fat pad or patellar tendon, iatrogenic intra-articular damage and neuroma of the infra-patellar branch of the saphenous nerve.[412131415] "
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    ABSTRACT: Background: Intramedullary nailing is the treatment of choice for the majority of tibial shaft fractures and anterior knee pain is the most common complication of this surgery; however, its etiology is still unknown. The purpose of this study was to assess the predicting factors related to anterior knee pain following tibial nailing. Materials and Methods: Patients with isolated, unilateral tibial shaft fracture who had undergone tibial nailing were identified retrospectively. Data including age, sex, type of fracture, technique of surgery and location of the nail were collected and finally the association between the above variables and knee pain were analyzed via SPSS software. Results: A total of 95 patients participated in the study. The mean age of the participants was 33.52 ± 1.62, 87 (91.6%) of whom were male and 74 (77.9%) had close fractures respectively. The method of surgery in 60 (63.2%) patients was paratendinous approach and in 35 (36.8%) was transtendinous. Twenty six (27.4%) of the patients had anterior knee pain. There were no significant differences between the two groups of patients with and without knee pain by age, sex, type of fracture and type of surgery (P = 0.952, 0.502, 0.212 and 0.745, respectively). Patients with protrusion of the nail from the anterior cortex had higher risk of developing knee pain after surgery (odds ratio: 2.76, confidence interval: 1.08, 7.08, P = 0.031). Conclusion: The results revealed a higher risk of developing anterior knee pain after tibial nailing in patients with protrusion of the nail from the anterior cortex.
    05/2014; 3(1):119. DOI:10.4103/2277-9175.133187
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    • "The distal introduction portal spares the knee joint and patella tendon. Anterior knee pain, which is the most common complaint of patients treated by antegrade tibial nailing is prevented [10] [11] [12] [13] [14]. "
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    ABSTRACT: Displaced distal tibia fractures require stable fixation while minimizing secondary damage to the soft tissues by the surgical approach and implants. Antegrade intramedullary nailing has become an alternative to plate osteosynthesis for the treatment of distal metaphyseal fractures over the past two decades. While retrograde intramedullary nailing is a standard procedure in other long bone fractures, only few attempts have been made on retrograde nailing of tibial fractures. The main reasons are difficulties of finding an ideal entry portal and the lack of an ideal implant for retrograde insertion.
    Injury 10/2013; 45. DOI:10.1016/j.injury.2013.10.025 · 2.14 Impact Factor
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    ABSTRACT: The ankle joint can be affected by several diseases, with clinical presentation varying from mild pain or swelling to inability, becoming in some cases a serious problem in daily life activities. Arthroscopy is a widely performed procedure in orthopedic surgery, due to the low invasivity compared to the more traditional open field surgery. The ankle joint presents anatomical specificities, like small space and tangential view that make arthroscopy more difficult. From 2000 more than 600 ankle arthroscopies were performed at our institution. The treated pathologies were mostly impingement syndrome and osteochondral lesions, and in lower percentage instabilities and ankle fractures. In the impingement, the AOFAS scores at FU showed an increase compared to scores collected preoperatively, with improvement of symptoms in most of the cases, good or excellent results in 80 % of cases. In ligament injuries, AOFAS score significatively improved at the maximum follow-up. In fractures all patients had an excellent AOFAS score at maximum follow-up, with complete return to their pre-injury activities. In osteochondral injuries, the clinical results showed a progressive improvement over time with the different performed procedures. Control MRI and bioptic samples showed a good regeneration of the cartilage and bone tissue in the lesion site. The encouraging obtained clinical results, in line with the literature, show how the arthroscopic technique, after an adequate learning curve, may represent a precious aid for the orthopedic surgeon and for the patient's outcome. Case series, Level IV.
    MUSCULOSKELETAL SURGERY 08/2013; 97(3). DOI:10.1007/s12306-013-0297-5
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