How to cite this article: Mohamed A-A. Fractures of the Proximal Third Tibia Treated With Intramedullary Interlocking Nails and Blocking Screws. Ortho & Rheum Open Access J. 2016; 2(4): 555592. DOI: 10.19080/OROAJ.2016.02.555592
Background: Internal splint age of proximal metaphyseal tibial fractures has gained acceptance as a method of early stabilization of such injuries. Intramedullary nailing is a challenging procedure .This study tries to evaluate treatment outcomes of closed reduction and intramedullary nailing with the aid of blocking screws to maintain the reduction and stabilize theses injuries.
Patients and Method: Thirty patients (23 males and 7 females) with proximal metaphyseal tibial fractures were treated and followed from June 2010 and February 2014 (44 months) with average 19 months. Age ranged between 23 to 55 years (average, 38 years). According to A.O. Classification 13 cases were Type A 2.1, 9 cases were Type A 2.1 (II), and 8 cases were Type A 3.2. Seven cases were open fractures and according to Gustilo Anderson classification 4 cases were Grade (I), 3cases were Grade (II). All cases were treated by interlocking intramedullary tibial nailing assisted by the use of blocking screws technique.
Results: The results had been evaluated through the following parameters: (pain, union, malunion, infection, range of motions, walking capacity, extension lag, knee stability and implant and technical failure. All cases had been united. Excellent alignment obtained in 27 fractures (90%). Knee and Ankle joints range of motions were equivalent to the unaffected side in 25 patients (82%). Two patients got superficial wound infection (2.7%). The final functional results were evaluated through modified Karlstrom-Olerud Score and we get: Excellent: 20 cases (66.7%), Good: 7 cases (23.3%), Satisfactory: 2 cases (6.7%) and Poor: 1 case (3.3%).
Discussion: Intramedullary nailing of proximal tibial fracture is a load sharing procedure, sparing the extraosseous blood supply, avoids additional soft-tissue dissection, thereby minimizing the risk of postoperative complications. Also, it reduces the length of hospital stay and costs, enables early mobilization and achieves satisfactory outcomes. However; it is a technically demanding procedure and may result in malalignment. Our aim is evaluating the clinical use of Pollar screws (blocking screws) as a supplement to stability fixation of these fractures with statically locked intramedullary nails.
Conclusion: Utilizing intramedullary interlocking nailing supplemented with blocking screws to aid in stabilizing proximal tibial fractures whether closed or open is a good method of treatment. The high proportions of excellent and good results in our series confirm that this technique is equal to other known methods of fracture fixation.
Proximal tibial fractures considered a more challenging injury. The goals of treating these fractures are: achieving bony union, restoring soft tissue vitality, preventing infection and instituting early joint motion and muscle rehabilitation . A wide variety of nonsurgical and surgical methods of treatment are available. They can be used in isolation or in interesting combinations involving two or more methods, depending on peculiarity of fracture, the age and health of the patient and other imperatives that might be imposed by associated injuries. Although intramedullary nailing becomes a standard biological procedure for managing diaphyseal fractures of long bones; it is still a debatable issue regarding its use in proximal tibial fractures .
Thirty patients with proximal tibial fractures were treated and followed between June 2010 and February 2014 (44 months) with average 19 months. There were 23 males and 7 females. Age ranged between 23 to 55 years (mean, 38years) years. In 17 cases (56.7%) fracture was due to road traffic accident, 11cases (36.6%) due to work related injuries, and in 2cases (6.7%) due to sport injuries. Seven cases were open (4were Grade (I) and 3 were Grade (II) according to Gustilo-Anderson classification .
According to the A.O. Classification: 13 cases were Type A 2.1 (medial oblique), 9 cases were Type A 2.1 (II) (lateral oblique), and 8 cases were Type A 3.2 (fragmented wedge) (Figure 1).
Exclusion criteria involved pathological fractures, adolescent
patients below 17 years old, patient with previous diaphyseal
fracture, non-united fractures and fractures extending to the
articular surface. Ethical clearance was obtained from the
institutional ethics committee and informed consent forms
from all patients were received. All cases were stabilized by
intramedullary interlocking tibial nails (8-10 mm of diameter
and 34 to 38 cm long).
Length and width of nail was provisionally determined
preoperatively. The proper nail assembled to the Distal Locking
Target Device to adjust distal locking screws position. All patients
had been operated-upon under general anesthesia and were
placed supine on a radiolucent table. For open fracture cases;
thorough irrigation was done utilizing 2-4 liters saline solution.
All contaminated, devitalized soft tissues were excised. Broad
spectrum antibiotic was given (3rd generation cephalosporin,
2 gm IV) just before induction and continued for 2 weeks. The
knee poisoned in 90 degree flexion. A longitudinal incision about
4 cm was made from the inferior pole of the patella just medial
to the patellar tendon, and extended distally. The infrapatellar
fat pad was identified and its insertion into the insertion into
the proximal tibia was sharply incised transversely allowing its
retraction superiorly for exposure of the proximal tibial ridge.
The entry point of nail detected and opened using a curved
Awl. Guide-wire passed through medullary canal down to level of
the fracture site under direct vision (in cases of Open fractures)
while utilizing image intensifier (in cases of closed fractures)
(Figure 2). The fracture was manipulated manually or by using
percutaneous clamp to achieve reduction. The guide wire then
was directed toward the distal fragment and its position was
checked again radiographicaly for further confirmation (Figure
3). Blocking screws were inserted percutaneously. The anteroposterior
screws were inserted in the distal aspect of the
proximal segment, just lateral to the central axis of the proximal
tibia. The sagittal plan screws placed in the posterior half of the
proximal part of the tibia from a medial to lateral direction. The
chosen nail attached to insertion jig and driven over the guide
wire through the medullary canal. Distal locking Target Device
assembled to the jig and distal locking screws were inserted first
(Figure 4), then the proximal ones (Figure 5). Wounds closed and dressed.
Wounds dressed every other day. Patients were mobilized
on first postoperative day where knee and ankle joints exercises
started. Partial weight bearing was encouraged for those who
had no other associated injuries prohibiting walking. Patients
were allowed for touch weight bearing on first post operative
day, half weight bearing for three weeks then full weight bearing when callus was seen on follow-up X-Rays. Supervised physical
therapy was initiated for thigh muscles strengthening and knee
range of motions exercises.
All patients agreed to present our timetable of follow up until
they get their fractures united and started pain free full weight
bearing. The patients were followed up postoperatively at 2 and
4 weeks, 3 months, 6 months, and 1 year. The mean length of
hospital stay was 6 days (range 2-19days). The results of the
study had been evaluated through: union of fracture, ranges
of motion of both knee and ankle joints, alignment of fracture,occurrence of infection, degree of knee pain, walking capacity,
extension lag and stability of the knee joint. All cases had been
united. Average union time was 15 weeks in 12 patients (40 %),
from 16-20 weeks in 15 patients (50%) from 21-28 weeks in
3 patients (10 %). There were no cases of nonunion. Knee and
ankle joints range of motions were measured using Goniometer.
In 25 patients (83.3%) it was equivalent to the unaffected side
but 3 patients (10%) got knee joint flexion restricted to about
85°, whereas 2 patients (6.7%) had 10- 15° restricted range of
ankle motions. Accuracy of reduction and final alignment were
evaluated via assessing the immediate postoperative and the
final follow-up radiographs.
Only 3 patients (10%) had malalignment. (Two of them had
10° and 40° varus angulation respectively and one case had 10°
valgus). Two patients got superficial wound infection (6.7%).
One of them got wound infection in the distal screw entry sites
and one patient got wound infection in the proximal nail entry
sites and both responded well to antibiotics. Regarding knee
pain, it was assessed after complete union of fractures. Twenty-
Two patients (73.3%) denied knee pain with any activity
whereas 8 (26.7%) patients had at least moderate knee pain
after vigorous activity. At last follow-up 28 patients were able
to walk freely without assistance (cane or crutches), while 2
patients used walking aid during free walking. Two patients had
extension lag about 100 while 3 patients had less than 15o lag
the rest of patients (25 patients) had no extension lag. Only one
patient had moderate knee instability. In our series No case of
neither implant nor technical failure developed. The overall final
functional results had been evaluated using Modified Karlstrom-
Olerud Score (Tables 1 & 2).
Controversy still remains regarding the use of IMN as a
definitive management of proximal third tibial fractures [4,5].
Historically, these injuries have been notoriously difficult to
fix and maintain without early failure in some reported series
. Malunion rates have been reported to be high and several
earlier series offered high rates of fracture failure, typically into
an apex anterior and valgus position [7,8] (Figure 6). The natural
bony anatomy and muscular attachments of the proximal tibia
offers the perfect set up for a number of common deformities
after fracture with subsequent malalignment during IMN
placement. These are due to muscular stresses via tendinous
attachments . The dynamic forces of the patellar tendon pull
the proximal fragment into an apex anterior angulation, whereas
the attachment of the pes anserinus causes valgus stress on the
same fragment (Figure 7).
These forces; in addition to the capacious medullary canal
at this level, create the potential for improper reduction and
suboptimal nail placement during nailing with conventional
techniques for IMN of proximal third tibial fractures with the
knee hyper flexed . Early frustrated results disappoint
surgeons from using of IMN for proximal third tibial fractures.
However, with continued research and proper understanding
of the specific anatomy and deforming forces surrounding the
proximal tibia; several technical modifications evolved that can
maintain reduction, restore native anatomy and consequently
improve outcome results. The accompanied studies exhibit high
rates of union and low resultant deformities which renewed the
interest of IMN usage for proximal third tibial fractures . Our
study outlines some of technical tricks and management pearls
available for treating proximal third tibial fractures via IMN,
with blocking screws in order to regain the normal mechanical
axis, proper length and neutral rotation .
In our series; the coronal plan blocking screws are inserted
in the distal aspect of the proximal segment, at a point just
lateral to the central axis of the proximal tibia (not the central
axis of the fracture); hence the nail passes medial to the blocking
screws. In the sagittal plane; blocking screws are placed in the
posterior half of the proximal part of the tibia (just posterior
to the central axis) from a medial to lateral direction allowing
the nail to remain to the anterior cortex as it is inserted down
the canal (Figure 8). The pollar screws which had been used
to supplement intramedullary nailing of tibial fractures would
improve stability of fixation and minimize the development of
angular deformity .
From mechanical point of view; Pollar screws function
through the principle of 3-point fixation. By this it would abolish
all forces exerted by muscles and ligaments on the proximal
tibial fragment. Also, it lessen the path via the metaphysic [7,13].
We revised some studies utilizing same technique of fixation
[10,11,13-15]. The prolonged period of follow-up which was not
issued by some studies gave us a chance to predict even minor
complications and those shortcomings that require very long
period of follow-up . The average age of patients was 34.4
years. This age group needed to return back to work as soon
as possible, so early mobilization is mandatory. Union could be
detected clinically when the patient is walking without pain on
the operated leg with full weight bearing and on radiological
examination bridging bone callus on at least three of the four
cortices in the Antero-posterior and lateral views is visible.
No cases of non-union developed in our series and these
results are more or less coincident with the results of other
studies [14,16,17]. Malunion was analyzed at the time of union
as the axis deviation between the proximal and distal fragment
at the level of the previous fracture, on the anteroposterior and
lateral x- rays. It was measured on long x-ray films and in some
cases CT scanogram was utilized. Avoidance of this complication
prohibits the development of joint pain and degenerative joint
disease . It was reported in 3 cases (10%); two of them
were due to technical defects and the third case showed sever
comminution and at the same time the patient bear weight
early without protection as recommended by many authors
. Although Seven patients (23.3%) in this study have open
fractures, there is a concern that performing an extended
incision (which requisite arthrotomy) may lead to pyarthrosis.
Despite this concern, just one patient with open injury
developed superficial infection. There was no cases of deep
infection and this may be attributed to proper management of
open fractures and preservation of soft tissue envelop around the
fracture ends in addition to adequate antibiotic coverage [19,20].
Range of motions of knee and ankle joints as a key for evaluating
efficiency of the technique was evaluated after complete union
of fracture. There were 25 cases (83.3%) regained full range of
motions for both knee and ankle joints and this attributed to
the early rehabilitation of the patient’s joints In 5 cases (16.7%)
the range of motions of knee and ankle joints were affected. All
of them related to open fractures (3 Grade (I) and 2 Grade (II)
which explains that the more the soft tissues damage the more
the delay of patient recovery which in turn affecting the nearby
joints range of motions .
The overall functional results were evaluated utilizing
Modified Functional Evaluation System by Karlstrom-Olerud
Score . They were as follows: Excellent: 20 cases (66.7%),
Good: 7 cases (23.3%), Satisfactory: 2 cases (6.7%) and Poor:
One case (3.3%) (Table 3). Giving details of surgical technique
as regard point of nail insertion, semi extended position during
nailing, polar screws to avoid deforming forces acting on the
proximal and distal fragments all are technical challenge to
attain perfect reduction and finally good results [11,23]. In
contrast to open reduction and internal fixation, intramedullary
nailing can be performed initially on the first or second day of
admission (Figure 9) presenting a female patient 25 years with
open fracture proximal right tibia (A), after using the mentioned
technique; the fracture fully united by 8 months (B), patient has
full knee extension (C) and can put full weight bearing (D).
The results of the study share the idea that tibial nailing of
proximal metaphyseal fractures aided by blocking screws being
a suitable procedure. The advantages include being a familiar
technique for fixing tibial shaft fractures; allows osteosynthesis
under biological aspects; no need to open the fracture site;
soft tissue dissection is not necessary; and the blood supply is
spared. It enables symmetric, dynamic and load-sharing fracture
stabilization without the need to restrict joint motion.
No benefits in any form have been received or will
be received from a commercial party related directly or
indirectly to the subject of this article.
Ethical approval: This article does not contain any
studies with animals.
Informed consent was obtained from all individual
participants included in the study according to the rules of
the hospital research ethical committee.
All procedures performed in our study were in accordance
with the ethical standards of the institutional research
committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards.