Intramedullary expert tibial nailing of distal tibial fractures: Functional outcomes with a midterm follow-up

Haazim Haneef Pandit; Zubair Younis Ringshawl; Shafeeq Ahmad Sofi; Imtiyaz Hussain Dar; Arshad Bashir; Mohammad Iqbal Wani

doi:10.4103/ijors.ijors_25_21

ORIGINAL ARTICLES

Year : 2021 | Volume : 29 | Issue : 2 | Page : 42-47

Intramedullary expert tibial nailing of distal tibial fractures: Functional outcomes with a midterm follow-up

Haazim Haneef Pandit, Zubair Younis Ringshawl, Shafeeq Ahmad Sofi, Imtiyaz Hussain Dar, Arshad Bashir, Mohammad Iqbal Wani
Department of Orthopaedics, Government Medical College, Srinagar, Jammu and Kashmir, India

Date of Submission	23-Jul-2021
Date of Decision	08-Aug-2021
Date of Acceptance	21-Nov-2021
Date of Web Publication	20-Dec-2021

Correspondence Address:
Zubair Younis Ringshawl
Department of Orthopaedics, Government Medical College, 152, S-3, L-4, Gulberg Colony, Hyderpora, Srinagar 190014, Jammu and Kashmir.
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijors.ijors_25_21

Abstract

Background: The tibial diaphysis is the most common site of fracture in the tibia and approximately 80% of these fractures have associated fibular fractures. Expert Tibia Nail System (ETNS) system provides extra stability in comparison to conventional intramedullary tibial nail due to multiaxial locking system. Objective: The aim of this study was to evaluate the midterm functional outcome of distal tibial fractures using the ETN. Materials and Methods: This prospective study was conducted from June 2016 to August 2019 comprising a total of 30 cases who were treated by Expert tibial nail fixation for distal tibial fractures. Clinical evaluation was done at each follow-up and final evaluation was done at 9 months postoperatively. The evaluation method at 9 months follow-up was the clinical examination and radiographic imaging. Results: Of 30 patients, majority were men. Male-to-female ratio was 3:1 with 22 men (73.33%) and 8 women (26.66%). The mean age of patients was 32 years with a range from 20 to 60 years. Left limb was involved more 16 (53.33%) frequently than right 14 (46.66%). Majority of the patients had trauma due to road traffic accidents (46.66%), fall from height/stairs (26.66%), twisting injuries (23.33%), and sports injuries (3.33%). There were 1 patient with superficial infection which resolved with wound care and antibiotics, 2 with anterior knee pain, 1 with malunion, 1 with delayed union, and 1 patient with nonunion. According to Johner and Wruh’s criteria, excellent results were achieved in 20 patients, good in 5 patients, fair in 4 patients, and poor in 1 patient. Conclusions: Expert tibial nailing is a new and innovative procedure for distal tibial fractures. It is safe and effective with the added advantage of providing additional stability and preventing rotational malalignment for distal third tibial fractures in comparison to conventional nailing. Further studies need to be conducted to validate the advantages of this procedure over conventional nailing.

Keywords: Distal third tibial fractures, Expert tibial nailing, intramedullary nailing

How to cite this article:
Pandit HH, Ringshawl ZY, Sofi SA, Dar IH, Bashir A, Wani MI. Intramedullary expert tibial nailing of distal tibial fractures: Functional outcomes with a midterm follow-up. Int J Orthop Surg 2021;29:42-7

How to cite this URL:
Pandit HH, Ringshawl ZY, Sofi SA, Dar IH, Bashir A, Wani MI. Intramedullary expert tibial nailing of distal tibial fractures: Functional outcomes with a midterm follow-up. Int J Orthop Surg [serial online] 2021 [cited 2023 Mar 26];29:42-7. Available from: https://www.ijos.in/text.asp?2021/29/2/42/332932

Introduction

Tibia is the most common fractured long bone in the body and has relatively high rates of malunion and nonunion.^[1] The tibial diaphysis is the most common site of fracture in the tibia and approximately 80% of these fractures have associated fibular fractures.^[2],[3] Because of its subcutaneous location, open fractures of the tibia are common with reported rates varying between 12% and 47%.^[3],[4] Open fractures are even more common with high-energy mechanisms with rates as high as 63% being reported following motorcycle crashes.^[5] Distal meta-diaphyseal fractures are more common after road traffic accident and sports injuries, and are distinct in terms of management and complication rates as compared to mid-diaphyseal fractures.

There are many treatment options in treating distal tibia fractures. Nonoperative treatment either by cast immobilization or functional bracing^[6] can be an option but multiple studies have shown poorer results when compared to intramedullary nailing.^{[2],[7],[8],[9]} External fixation of tibial diaphyseal fractures has been used for over 100 years but recently there has been a growing interest in the use of modern ring fixators.^{[10],[11],[12],[13],[14]} But external fixation too comes with many pitfalls such as pin track infection, loss of fracture alignment, and nonunion. Minimally invasive percutaneous plate osteosynthesis (MIPPO) is a well-documented technique that offers biological advantages; however, it too has many disadvantages such as wound site infection and skin impingement by implant.^[15] For distal tibial fracture, Expert tibial nail (ETN) overcomes all issues encountered by the conventional nails, plates, or external fixation.

Materials and Methods

The aim of this study was to evaluate the midterm functional outcome of distal tibial fractures using the ETN. This study was conducted in the Postgraduate Department of Orthopaedics of our institute. After obtaining approval from Institutional Ethical Committee, various modalities of treatment were discussed with the patient and after that written informed consent was taken for participation in this study. This prospective study consisted of a total of 30 cases who were selected based on the inclusion and exclusion criteria of the study [Table 1]. ETN fixation was done for distal tibial fractures. Clinical evaluation was done at each follow-up and final evaluation was done at 9 months postoperatively. The evaluation method at 9 months follow-up was clinical examination and radiographic imaging. Johner and Wruh’s criteria was used to evaluate the final result [Table 2].

Table 1: Inclusion and exclusion criteria for intramedullary Expert nailing for distal tibial fracture

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Table 2: Johner and Wruh’s criteria for evaluation of final result

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Operative technique

After anesthetic checkup, patients were taken for surgical procedures. Prophylactic antibiotics (cefuroxime 25 mg/kg)^[16] were given 1 h before the surgical procedure. Usually, spinal anesthesia was the preferred choice. The patients were placed in supine position on the radiolucent table ensuring that the knee of the injured leg can be flexed until at least 90°–110°.^[6] After proper draping of the involved limb, closed reduction was performed manually by axial traction under an image intensifier (to correct the mediolateral and anteroposterior (AP) angulation). Trafton’s^[17] criteria was used to accept the reduction (mediolateral angulation <5°, AP angulation <10°, and rotation <10°). Nail size was determined after reduction under the image intensifier. Most of the time, tibial fractures were associated with fibular fractures. In case of unstable comminuted fractures of tibia with distal one-third fractures of fibula, reduction of tibial fractures was difficult. Therefore in such cases, fibula was fixed first. Fibular fixation was achieved by either intramedullary rush nail or by plating depending upon the fracture configuration. After reduction, entry was made in the tibia after giving 3–4 cm incision proximally at the distal third of patella along the patellar tendon down to the tibial tuberosity [Figure 1]. Entry site of the nail was made on the ventral edge of the tibial plateau. The entry wound was in line with the axis of the intramedullary canal and with the lateral tubercle of the intercondylar eminence in AP view, and the entry point was in line with the ventral edge of the tibial plateau in lateral view. A guidewire was secured on the universal chuck and inserted at an angle of 10° to the shaft in lateral view. The cannulated awl was placed over the guidewire and the medullary canal opened using a twisting motion to advance the awl taking care not to open the posterior cortex. Serial reaming was done after putting the ball-tipped guidewire. Appropriate size and diameter of ETN were put in and in the case of mismatch between the diameter of nail and medullary cavity and persistent malalignment (especially in coronal planes) blocking/poller screws were used.^[18] After acceptable reduction, nail was locked proximally and distally. The distal screws were inserted by using freehand technique. The distal locking screws were put in multiple planes. Wound wash was done, wound was stitched back, and aseptic dressing was applied. Distal neurovascular status (DNVS) was checked.

Figure 1: Surgical technique for making entry point which started with skin markings (A and B) followed by incision and soft-tissue dissection (C and D) and then entry point was made using awl (E)

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Postoperative rehabilitation protocol

On the first postoperative day, any wound soakage or fresh complaint was assessed along with DNVS. Standard AP and lateral radiographs were taken. Static quadriceps exercises/range of motion of knee and ankle was started. Patients were mobilized on walker and advised toe-touch weight-bearing. Patients were discharged from the hospital on the third postoperative day. Intravenous antibiotics were given for 3 days followed by oral antibiotics for up to 5 days.

Follow-up

The patients were followed at 2 weeks, 6 weeks, and then monthly up to 6 months and with a final follow-up at 9 months. At 2-week follow-up, wound infection/tenderness/DNVS was checked, sutures were removed, AP and lateral radiographs were taken to check alignment, and patients were advised weight-bearing as tolerated. In subsequent follow-ups, clinico-radiological assessment was done. Residual symptoms, fracture tenderness, shortening, deformity, and muscle atrophy were checked clinically. Alignment, fracture union, and implant status were assessed radiologically.

Results

Majority of the patients in our study were men. Male-to-female ratio was 3:1 with 22 men (73.33%) and 8 women (26.66%). The mean age of patients was 32 years with a range from 20 to 60 years. Left limb was involved in 16 patients (53.33%), which was more than right limb, involved in 14 (46.66%). Majority of the patients had trauma due to road traffic accidents (RTAs) (46.66%), fall from height/stairs (26.66%), twisting injuries (23.33%), and sports injuries (3.33%). There were 24 patients with type 43A1 (80%), 4 with type 43A2 (13.33%), and 2 with type 43A3 (6.66%) fractures according to OA\OTA classification. Average time lag between traumatic event and surgery was 1.4 days. The mean time taken for surgery was 66.6 min with a range from 52 to 80 min. The total range of hospital stay was from 3 to 12 days with an average of 4 days. Full weight-bearing was started between 8 and 19 weeks with a mean time for full weight-bearing at 10 weeks. The average time taken for the complete radiological union was 17 weeks. There was only one patient where there was a radiological malalignment in the coronal plane, rest all the patients had no radiological malalignment according to Trafton’s criteria. There were two patients with anterior knee pain, one patient with superficial infection which resolved with wound care and antibiotics, one with malunion, one with delayed union, and one patient with nonunion. According to Johner and Wruh’s criteria, excellent results were achieved in 20 patients, good in 5 patients, fair in 4 patients, and poor in 1 patient. The radiological result of a patient showed solid fracture union [Figure 2] with excellent clinical results [Figure 3].

Figure 2: Radiographs of a patient of fracture tibio-fibula: preoperative (A), postoperative (B), and radiographs at final follow-up after Expert nailing (C)

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Figure 3: Clinical photographs of a patient showing functional results at final follow-up: full flexion of knees (A), plantarflexion and dorsiflexion of ankle (B and C), and gait while steeping up and down (D)

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Discussion

Expert Tibia Nail System (ETNS) was introduced worldwide in 2005 as universal tibial intramedullary implant. It is a new-generation implant that overcomes the problems encountered by conventional nails. Several technical modifications compared to standard tibial nails are incorporated in the design of this nail. This system provides extra stability in comparison to conventional intramedullary tibial nail due to the multiaxial locking system.^[6] It has five proximal locking options and four distal locking options. Advanced proximal locking options with three unique and innovative locking options, in combination with cancellous bone locking screws for optimized stabilization of proximal fragment and two mediolateral locking options, enable primary compression or secondary controlled dynamization. Advanced distal locking options include one oblique locking option which can be placed very distally, allowing optimized bone purchase and preventing damage of soft tissue, and two medio-lateral and one AP locking options for better stabilization of distal fragment. ETNS has an end cap that has the advantage to block one oblique locking screw which provides absolute angular stability,^[7] prevents in-growth of tissues and facilitates nail extractions and self-holding star drive recess for effortless and secure end cap pick up.

Nail design

ETN is an intramedullary implant with optimized geometry at its proximal end. Due to combined results from different centers, it was found that the location and degree of Herzog bend influences nail insertion and nail stability, so the prototype nail was modified by adding 2° inclined to 8° proximal nail radius for a better fit in the medullary canal and easier insertion and the removal of nail. ETN is available in lengths between 25.5 and 46.5 cm in 15 mm steps. The solid version for unreamed technique is available in diameters of 8, 9, and 10 mm, whereas the cannulated version that can be used for reamed as well as unreamed technique is available in diameters of 8, 9, 10, 11, 12, and 13 mm.

In our study of 30 patients with extra-articular fractures of distal tibia within 4–9 cm from plafond, age ranged from 20 to 60 years. Young adults were found to be most commonly involved among all age groups with a mean age of 32 years. This was slightly younger than the studies conducted by Gawatre et al.,^[19] where the mean age group was 38 years, Yadav et al.,^[6] where the mean age group was 42 years, and Kachhap et al.,^[20] where the mean age group was 37 years. More involvement of young individuals in our study can be attributed to the trend of an increasing number of population of young adults in this part of the subcontinent and increased road traffic accidents.

In this study, more susceptible sex was of males (73.33%) which is comparable to other studies conducted by Gawatre et al.,^[19] Yadav et al.,^[6] and Kachhap et al.^[20]

Of 30 patients, 16 (53.33%) had left side and 14(46.66%) had right side involvement. It was contradictory to the results of the studies conducted by Yadav et al.^[6] and Kachhap et al.,^[20] where the right side was predominantly involved. The predominant mode of trauma in our study was RTA which was comparable with studies conducted by Gawatre et al.^[19] and Yadav et al.^[6]

Time interval to surgery in our series ranged from 1 to 15 days, which is comparable with other studies. The hospital study ranged from 6 to 20 days with a mean of 10 days. Most of the hospital stay was preoperative and approximately 90% of patients were discharged from the hospital on the third postoperative day. The operative time ranged from 50 to 80 min with an average of 65 min and the results were comparable to other studies.

The average time to full weight-bearing in our study was 10 weeks, which is comparable with studies conducted by Yadav et al.^[6] and Li et al.,^[21] where the average time was 8 and 9 weeks, respectively. The most common type of fracture seen in our study was 43A1 followed by 43A2.

Union time in our patients was an average of 17 weeks, which was comparable with other studies.^{[6],[19],[22]} There was only one patient where there was a radiological malalignment (7° valgus) in the coronal plane, rest all the patients had no radiological malalignment according to Trafton’s criteria. Our results are better in this parameter as compared to other studies.^[19],[23]

There were two patients with anterior knee pain, one patient with superficial wound infection which resolved with wound care and antibiotics, one with malunion, one with delayed union, and one patient with nonunion. In the two patients who developed delayed union, one patient united at final follow-up and another patient continued as nonunion even after dynamization. The incidence of complications was slightly lower in our studies as compared to the other studies.^{[6],[19.],[21]}

In our study, at final follow-up, 20 patients (66.6%) had excellent results, 5 patients (16.66%) had good results, 4 patients (13.33%) had fair results, and 1 patient (3.33%) had poor results according to Johner and Wruh’s criteria. This was comparable with the other study.^[6]

Conclusion

Expert tibial nailing is a new and innovative procedure for distal tibial fractures. It is safe and effective with the added advantage of additional stability for distal third tibial fractures in comparison to conventional nailing. Further studies need to be conducted to validate the advantages of this procedure over conventional nailing.

Acknowledgement

This manuscript represents the honest work performed in the Department of Orthopaedics, Govt. Hospital for Bone and Joint Surgery (an associated hospital of Govt. Medical College, Srinagar).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

References

1.	Puno RM, Teynor JT, Nagano J, Gustilo RB. Critical analysis of results of treatment of 201 tibial shaft fractures. Clin Orthop 1986;212:113-21.
2.	Alho A, Benterud JG, Høgevold HE, Ekeland A, Strømsøe K . Comparison of functional bracing and locked intramedullary nailing in the treatment of displaced tibial shaft fractures. Clin Orthop Relat Res1992;277:243-50.
3.	Weiss RJ, Montgomery SM, Ehlin A, Al Dabbagh Z, Stark A, Jansson KA. Decreasing incidence of tibial shaft fractures between 1998 and 2004: Information based on 10,627 Swedish inpatients. Acta Orthop 2008;79:526-33.
4.	Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators; Bhandari M, Guyatt G, Tornetta P 3rd, Schemitsch EH, Swiontkowski M, Sanders D, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am 2008;90:2567-78.
5.	Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg Br 1995;77:417-21.
6.	Yadav L, Srivastava S, Kumar R, Garg G, Hussain J, Sharma SK. Functional outcome of expert tibial intramedulary nailing for metaphyseal and diaphyseal fractures of tibia. IOSR J Dent Med Sci 2017;15:70-4.
7.	Bone LB, Sucato D, Stegemann PM, Rohrbacher BJ. Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing: An outcome analysis of matched pairs of patients. J Bone Joint Surg Am 1997;79:1336-41.
8.	Hooper GJ, Keddell RG, Penny ID. Conservative management or closed nailing for tibial shaft fractures: A randomised prospective trial. J Bone Joint Surg Br 1991;73:83-5.
9.	Karladani AH, Granhed H, Edshage B, Jerre R, Styf J. Displaced tibial shaft fractures: A prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients. Acta Orthop Scand 2000;71:160-7.
10.	Hutson JJ Jr, Dayicioglu D, Oeltjen JC, Panthaki ZJ, Armstrong MB. The treatment of Gustilo grade IIIB tibia fractures with application of antibiotic spacer, flap, and sequential distraction osteogenesis. Ann Plast Surg 2010;64:541-52.
11.	Keeling JJ, Gwinn DE, Tintle SM, Andersen RC, McGuigan FX. Short-term outcomes of severe open wartime tibial fractures treated with ring external fixation. J Bone Joint Surg Am 2008;90:2643-51.
12.	Wani N, Baba A, Kangoo K, Mir M. Role of early ilizarov ring fixator in the definitive management of type II, IIIA and IIIB open tibial shaft fractures. Int Orthop 2011;35:915-23.
13.	Court-Brown CM, Hughes SP. Hughes external fixator in treatment of tibial fractures. J R Soc Med 1985;78:830-7.
14.	Henley MB, Chapman JR, Agel J, Harvey EJ, Whorton AM, Swiontkowski MF. Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: A prospective comparison of unreamed interlocking intramedullary nails and half-pin external fixators. J Orthop Trauma 1998;12:1-7.
15.	Asif N, Siddiqui YS, Jain JK, Zahid M, Abbas M, Sabir AB, et al. Minimally invasive percutaneous plate osteosynthesis (MIPPO) in distal tibial fracture: A prospective study from developing nation. J Trauma Treat2014 (Suppl 2):009. doi:10.4172/2167-1222.S2-009.
16.	Geroulanos S, Marathias K, Kriaras J, Kadas B. Cephalosporins in surgical prophylaxis. J Chemother 2001;13:23-6.
17.	Trafton PG. Closed unstable fractures of the tibia. Clin Orthop Relat Res 1998;230:58-67.
18.	Krettek C, Stephan C, Schandelmaier P, Richter M, Pape HC, Miclau T. The use of poller screws as blocking screws in stabilising tibial fractures treated with small diameter intramedullary nails. J Bone Joint Surg Br 1999;81:963-8.
19.	Gawatre PR, Chavali VH, Shah HD, Daveshwar RN. Distal metaphyseal fractures of Tibia treated by multiaxial locked intramedullary nail: A study of 43 cases. Int J Sci Res2016;5.
20.	Kachhap ND, Kumar A, Kumar MM, Kumar D, Kumar B, Kumar D. To study outcome of surgical management of distal 3rd and proximal 3rd fractures of tibia in adults using expert tibial nails. Int J Res Orthop 2017;3:862-6.
21.	Li Y, Liu L, Tang X, Pei F, Wang G, Fang Y, et al. Comparison of low, multidirectional locked nailing and plating in the treatment of distal tibial metadiaphyseal fractures. Int Orthop 2012;36:1457-62.
22.	Mahmood A, George JJ, Malal S, Majeed A. Outcome of expert tibial nailing for distal third tibial fractures. Orthop Proc2012.
23.	Attal R, Hansen M, Kirjavainen M, Bail H, Hammer TO, Rosenberger R, et al. A multicentre case series of tibia fractures treated with the expert tibia nail (ETN). Arch Orthop Trauma Surg 2012;132:975-84.