J Korean Orthop Assoc.  2014 Aug;49(4):294-301. 10.4055/jkoa.2014.49.4.294.

Interlocking Intramedullary Nailing for Far Distal Tibia Fractures in AO Classification 43

• Lee JY
• Lee SJ
• Ha SH
• Choi KY

• KMID: 2185185
• DOI: http://doi.org/10.4055/jkoa.2014.49.4.294

Abstract

PURPOSE
This retrospective study was conducted in order to evaluate the results of interlocking intramedullary nailing of far distal tibia fractures located within AO classification 43.
MATERIALS AND METHODS
Seventy patients with far distal tibia fractures in AO classification 43 treated with interlocking intramedullary nailing from May 2008 to April 2012 were evaluated. The minimum follow-up period was 12 months. We analyzed preoperative fracture pattern, associated injury, and complication. All cases were treated with use of either two or three distal interlocking screws during intramedullary nailing. Patients received regular post-operative radiographic check-up and ankle function was evaluated using the Iowa ankle-evaluation rating system.
RESULTS
The fractures healed completely within an average of 18 weeks. None of the patients showed malaligment on the final radiographic evaluation. Average of varus-valgus aligment was 1.9 degrees and average of anterior-posterior alignment was 1.1 degrees. According to the Iowa ankle-evaluation rating system, we obtained satisfactory clinical results in 14 cases. Complication occurred in two cases. There was one case of hypertrophic nonunion and one breakage of the distal locking screw with delayed union.
CONCLUSION
We consider that interlocking intramedullary nailing of far distal tibia fractures located within AO classification 43 is a considerable method when a plate is not used due to accompanying severe open wound, etc. For satisfactory results, accurate technique and experience of the operator were required.

Keyword

tibia; tibial fracrture; intramedullary nailing

MeSH Terms

Ankle
Classification*
Follow-Up Studies
Fracture Fixation, Intramedullary*
Humans
Iowa
Retrospective Studies
Tibia*
Wounds and Injuries

Figure

• 

  Figure 1 Fluoroscopic X-rays show use of the poller screw for accurate insertion of the nail. Ball tip guide insertion (A), using the poller screw before nail insertion (B), accurate nail insertion at the site (C), distal interlocking screw fixation (D). Postoperative X-ray, anteroposterior (E), and lateral view (F).

• 

  Figure 2 A 53-year-old man had a tibia fracture in AO classification 43-A1 after slipping and falling down. Internal fixation with an interlocking nail was performed. Postoperative four-month radiograph shows the healed distal tibia fracture.

Reference

1. Court-Brown CM, Christie J, McQueen MM. Closed intramedullary tibial nailing. Its use in closed and type I open fractures. J Bone Joint Surg Br. 1990; 72:605–611.

2. Wyrsch B, McFerran MA, McAndrew M, et al. Operative treatment of fractures of the tibial plafond. A randomized, prospective study. J Bone Joint Surg Am. 1996; 78:1646–1657.

3. Teeny SM, Wiss DA. Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications. Clin Orthop Relat Res. 1993; 292:108–117.

4. Klemm KW, Börner M. Interlocking nailing of complex fractures of the femur and tibia. Clin Orthop Relat Res. 1986; 212:89–100.

5. Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF. A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma. 2000; 14:187–193.

6. Whittle AP, Russell TA, Taylor JC, Lavelle DG. Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming. J Bone Joint Surg Am. 1992; 74:1162–1171.

7. Böstman O, Hänninen A. The fibular reciprocal fracture in tibial shaft fractures caused by indirect violence. Arch Orthop Trauma Surg. 1982; 100:115–121.

8. Tyllianakis M, Megas P, Giannikas D, Lambiris E. Interlocking intramedullary nailing in distal tibial fractures. Orthopedics. 2000; 23:805–808.

9. Konrath G, Moed BR, Watson JT, Kaneshiro S, Karges DE, Cramer KE. Intramedullary nailing of unstable diaphyseal fractures of the tibia with distal intraarticular involvement. J Orthop Trauma. 1997; 11:200–205.

10. Rüedi TP, Allgöwer M. Fractures of the lower end of the tibia into the ankle-joint. Injury. 1969; 1:92–99.

11. Gustilo RB, Mendoza RM, Williams DN. Problems in management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984; 24:742–746.

12. Merchant TC, Dietz FR. Long-term follow-up after fractures of the tibial and fibular shafts. J Bone Joint Surg Am. 1989; 71:599–606.

13. Martin JS, Marsh JL, Bonar SK, DeCoster TA, Found EM, Brandser EA. Assessment of the AO/ASIF fracture classification for the distal tibia. J Orthop Trauma. 1997; 11:477–483.

14. Anglen JO. Early outcome of hybrid external fixation for fracture of the distal tibia. J Orthop Trauma. 1999; 13:92–97.

15. Pugh KJ, Wolinsky PR, McAndrew MP, Johnson KD. Tibial pilon fractures: a comparison of treatment methods. J Trauma. 1999; 47:937–941.

16. Krettek C, Miclau T, Schandelmaier P, Stephan C, Möhlmann U, Tscherne H. The mechanical effect of blocking screws ("Poller screws") in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter intramedullary nails. J Orthop Trauma. 1999; 13:550–553.

17. Nork SE, Schwartz AK, Agel J, Holt SK, Schrick JL, Winquist RA. Intramedullary nailing of distal metaphyseal tibial fractures. J Bone Joint Surg Am. 2005; 87:1213–1221.

18. Collinge C, Protzman R. Outcomes of minimally invasive plate osteosynthesis for metaphyseal distal tibia fractures. J Orthop Trauma. 2010; 24:24–29.

19. Helfet DL, Suk M. Minimally invasive percutaneous plate osteosynthesis of fractures of the distal tibia. Instr Course Lect. 2004; 53:471–475.

20. Vallier HA, Le TT, Bedi A. Radiographic and clinical comparisons of distal tibia shaft fractures (4 to 11 cm proximal to the plafond): plating versus intramedullary nailing. J Orthop Trauma. 2008; 22:307–311.

21. Robinson CM, McLauchlan GJ, McLean IP, Court-Brown CM. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br. 1995; 77:781–787.