Article

Intramedullary Nailing of Distal Metaphyseal Tibial Fractures

Department of Orthopaedic Surgery, University of California, San Diego, San Diego, California, United States
The Journal of Bone and Joint Surgery (Impact Factor: 5.28). 06/2005; 87(6):1213-21. DOI: 10.2106/JBJS.C.01135
Source: PubMed

ABSTRACT

The treatment of distal metaphyseal tibial fractures remains controversial. This study was performed to evaluate the results of intramedullary nailing of distal tibial fractures located within 5 cm of the ankle joint.
Over a sixteen-month period at two institutions, thirty-six tibial fractures that involved the distal 5 cm of the tibia were treated with reamed intramedullary nailing with use of either two or three distal interlocking screws. Ten fractures with articular extension were treated with supplementary screw fixation prior to the intramedullary nailing. Radiographs were reviewed to determine the immediate and final alignments and fracture-healing. The Short Form-36 (SF-36) and Musculoskeletal Function Assessment (MFA) questionnaires were used to evaluate functional outcome.
Acceptable radiographic alignment, defined as <5 degrees of angulation in any plane, was obtained in thirty-three patients (92%). No patient had any change in alignment between the immediate postoperative and the final radiographic evaluation. Complications included one deep infection and one iatrogenic fracture at the time of the intramedullary nailing. Six patients could not be followed. The remaining thirty fractures united at an average of 23.5 weeks. Three patients with associated traumatic bone loss underwent a staged autograft procedure, and they had fracture-healing at an average of 44.3 weeks. The functional outcome was determined at a minimum of one year for nineteen patients and at a minimum of two years (average, 4.5 years) for fifteen patients. At one year, there were significant limitations in several domains despite fracture union and maintenance of alignment, but there was improvement in the MFA scores with time.
Intramedullary nailing is an effective alternative for the treatment of distal metaphyseal tibial fractures. Simple articular extension of the fracture is not a contraindication to intramedullary fixation. Functional outcomes improve with time.

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    • "Intramedullary nailing (IMN) is also an optional technique. But the side effects, such as postoperative knee pain, destruction of the endomedullary blood supply with more hidden blood loss, iatrogenic propagation of the fracture, inadequate distal fixation and hardware failure leading to malunion, should be taken into consideration [8] [9] [10]. The external fixator (EF) has a defined place in the primary treatment, for its simple process, slight soft-tissue affection, no periosteal stripping and less blood-supply destruction in the fracture site [4] [11] [12]. "
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    ABSTRACT: Introduction: Several techniques have been described to treat tibial fractures, which respectively remains defects. This article presents a novel intra- and extramedullary fixation technique: percutaneous external fixator combined with titanium elastic nails (EF-TENs system). The purpose of this study is to introduce this new minimally invasive surgical technique and selective treatment of tibial fractures, particularly in segmental fractures, diaphysis fractures accompanied with distal or proximal bone subfissure, or fractures with poor soft-tissue problems. Methods: Following ethical approval, thirty-two patients with tibial fractures were treated by the EF-TENs system between January 2010 and December 2012. The follow-up studies included clinical and radiographic examinations. All relevant outcomes were recorded during follow-up. Results: All thirty-two patients were achieved follow-ups. According to the AO classification, 3 Type A, 9 Type B and 20 Type C fractures were included respectively. According to the Anderson-Gustilo classification, there were 5 Type Grade II, 3 Type Grade IIIA and 2 Type Grade IIIB. Among 32 patients, 8 of them were segmental fractures. 12 fractures accompanied with bone subfissure. Results showed no nonunion case, with an average time of 23.7weeks (range, 14-32weeks). Among them, there were 3/32 delayed union patients and 0/32 malunion case. 4/32 patients developed a pin track infection and no patient suffered deep infection. The external fixator was removed with a mean time of 16.7 weeks (range, 10-26 weeks). Moreover, only 1/32 patient suffered with the restricted ROM of ankle, none with the restricted ROM of knee. Conclusion: This preliminary study indicated that the EF-TENs system, as a novel intra- and extramedullary fixation technique, had substantial effects on selective treatment of tibial fractures.
    Preview · Article · Oct 2015 · Injury
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    • "221 37 Sirkin [47] 97 70 Mundermann [80] 65 4 Mann [14] 211 38 Williams [48] 96 71 Giannini [81] 65 5 Laaveg [15] 209 39 Nawoczenski [49] 94 72 Martin [82] 64 6 Kannus [16] 207 40 Mueller [50] 93 73 Paoloni [83] 63 7 Bostman [17] 189 41 Knecht [51] 92 74 Coughlin [84] 63 8 Funk [18] 167 42 Ogden [52] 92 75 Kofoed [85] 62 9 Cooper [19] 166 43 Stacoff [53] 92 76 Burnfield [86] 62 10 Bucholz [20] 157 44 Kumai [54] 92 77 Gobbi [87] 61 11 Lentell [21] 151 45 Armstrong [55] 92 78 Buechel [88] 61 12 Gerber [22] 144 46 Redmond [56] 90 79 Clare [89] 61 13 Coester [23] 143 47 Hodge [57] 90 80 Hunt [90] 61 14 Vail [24] 138 48 Shepherd [58] 88 81 Bibbo [91] 60 15 Rozzi [25] 134 49 Chiari [59] 86 82 Giannini [92] 59 16 Sangeorzan [26] 131 50 Tol [60] 86 83 Whittaker [93] 58 17 Wood [27] 129 51 Van Dijk [61] 86 84 Digiovanni [94] 58 18 Ponseti [28] 128 52 Khan [62] 85 85 Gautier [95] 57 19 Ekstrand [29] 128 53 Dobbs [63] 85 86 Bonnin [96] 53 20 Pyevich [30] 125 54 Spirt [64] 84 87 Thomas [97] 53 21 Bernier [31] 122 55 Acevedo [65] 82 88 Button [98] 52 22 Konradsen [32] 122 56 Hintermann [66] 80 89 Fuchs [99] 52 23 Teeny [33] 118 57 Beynnon [67] 80 90 Buechel [100] 51 24 Hopkinson [34] 118 58 Easley [68] 80 91 Pollak [101] 51 25 Mcilroy [35] 116 59 Ohberg [69] 79 92 Baums [102] 50 26 Pfeffer [36] 115 60 Haddad [70] 78 93 Nork [103] 49 27 Georgiadis [37] 113 61 Valderrabano [71] 76 94 Kay [104] 49 28 Anderson [38] 110 62 Coughlin [72] 75 95 Hertel [105] 48 29 Sanders [39] 109 63 Digiovanni [73] 74 96 Vallier [106] 47 30 Hangody [40] 108 64 Roos [74] 74 97 Dobbs [107] 46 31 Kitaoka [41] 108 65 Taranow [75] 72 98 Weening [108] 46 32 Riddle [42] 104 66 Minami [76] 69 99 Bus [109] 46 33 Hoffman [43] 102 67 Ippolito [77] 67 100 Henricson [110] 45 34 Papa [44] "
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    ABSTRACT: Background The number of citations of a paper gives an indication of an article's merit and importance within a medical specialty. We identify and analyse the 100 most cited papers in foot and ankle surgery. Method The Science Citation Index Expanded was searched for citations in 15 respected journals containing foot and ankle articles. Papers were analysed for subject, authorship, institution, country and year of publication. The average yearly citation was compared to total number of citations. Results 3,501 foot and ankle papers were returned. The maximum number of citations was 1084 and the mean was 104. The top 100 papers were published between 1979 and 2007, with the majority published in the last decade. The ankle was the most important anatomical region discussed, and basic science and degenerative disease were popular topics. We found a large discrepancy between the total number of citations with average yearly citation. Conclusion Foot and ankle surgery is a young and rapidly developing sub-specialty within orthopaedics. Recently there has been a significant increase in influential papers published. Certain topics are popular indicating their importance within the field. This study highlights important papers in foot and ankle surgery giving an insight into readership.
    Full-text · Article · Jan 2013 · The Foot
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    • "Varsalona and Liu reported that in extra-articular fractures of combined tibia and fibula, fixation of the fibula has no benefit and is not recommended [14]. Nork et al. and Obremsky and Medina express no effect of fibular fixation on treatment outcome of patients with tibial fractures, also they reported that IMN is an effective alternative with less malalignment and complications for the treatment of distal metaphyseal tibial fractures [17] [18], that was correlated with our study. Third group of studies comment some beneficial effects of fibular fixation in same level combined tibial and fibular fractures and have suggested concurrent fibular fixation. "
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    ABSTRACT: Introduction Combined fractures of the distal third of tibia diaphysis and fibula diaphysis are a common orthopedic injury. There is an ongoing debate about the necessity of fibular fixation when associated to distal third tibial fracture. This study aims at evaluating the role of fibular fixation in the treatment of distal third tibial fractures. Hypothesis We hypothesized that fixation of the fibula increases the stability of fixation in distal third tibial and fibular fractures. Materials and methods In a randomized clinical trial, 53 patients with concomitant fractures of tibia and ipsilateral fibula at distal third level were recruited in this study during a 23-month period. Patients were randomized in two groups: patients with fibular fixation (case group) and without fibular fixation (control group). The patients were followed up for at least 6 months postoperatively. Results There were seven cases exhibiting malalignment on immediate postoperative radiographs. Six of them were in group II (control group) and 1 was in group I (case group) (P = 0.084). We didn’t find nonunion in group I and we found three patients in group II (P = 0.141). Infection was 1 in group I and 2 in group II on gustillo II injuries (P = 0.516). Conclusion Despite its low count of patients, our study didn’t show any advantage to fix the fibula fracture associated to distal third of tibia diaphysis fracture. It didn’t show either an increase of complication after fibula open reduction and internal fixation. Level of evidence Level III. Randomized prospective study.
    Full-text · Article · Dec 2012 · Revue de Chirurgie Orthopédique et Traumatologique
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