[Combination of intramedullary nail and covered screw osteosynthesis for managing distal tibial fracture with ankle joint involvement]

E H Rzesacz, W Könneker, H Reilmann, U Culemann
Der Unfallchirurg 1998, 101 (12): 907-13
Fractures of the distal metaphysis of the tibia often include an extension into the ankle. Intramedullary nailing combined with covered screw osteosynthesis should reduce the high incidence of soft tissue and ankle problems and should be an alternative to open plate fixation, with good ultimate functional outcome. Between January 1993 and December 1995, a prospective study on 49 patients with distal metaphyseal tibia fracture and involvement of the ankle was performed. All the fractures were treated with intramedullary nailing combined with covered screw osteosynthesis, and plate fixation in cases of fibula fractures. There were 27 men and 22 women with an average age of 46.4 +/- 12.7 years (range 21-90). In most studies of the use of intramedullary nailing in distal tibial fractures the classification has been inadequate. Therefore a new classification according to Robinson et al. (1995) was used: 10 fractures were type II B (20.4%), 13 were type II C (26.5%), and 26 patients suffered a combination of type II B and type II C (53.1%). This fracture type was defined as type II D for use in this study. The severity of soft tissue injury was recorded using the Gustilo system in case of open (n = 19) and the Tscheme system in case of closed fractures (n = 30). In 31 patients distal tibia fracture was accompanied by a fracture of the fibula, which was first stabilized using a plate. For reconstruction of the distal articular surface, covered screw osteosynthesis was done. At the next step intramedullary nails were inserted and were statically locked proximally and distally. From January 1993 to February 1994, the reamed AO standard nail was used. After introduction of the unreamed tibial nail (UTN) all fractures were treated by this implant. Full load on the operated leg was allowed after 8 weeks. Union of the fracture was assessed by standard radiological and clinical criteria. Misalignment was defined as more than 5 degrees of angular rotation. Further surgery due to a valgus deformity in the ankle joint had to be done in three cases. There were no deep infections. Three patients had a superficial infection in the ankle area, but surgical debridement was not necessary. A leg shortening was found in 4 cases, but it was less than 1 cm in every case. Therefore, surgical correction was not done. Patients were reviewed at intervals of 2, 6, and 12 weeks, and after 6, and at least 12 months. All 49 patients were finally reviewed after an average time of 15.7 months (range 12-38). Bone fusion was reached 12.8 weeks (range 9-21) after the operative treatment. A specific assessment of the ankle symptoms was made using the score of Olerud and Molander (1984). In 29 patients excellent results were recorded. A satisfactory result was attained with 17 patients and just 3 patients were found to be unsatisfactory. Although proximity of distal tibia fracture to the ankle makes the treatment more complicated than for fractures of the tibial diaphysis, closed intramedullary nailing combined with covered screw fixation is a good alternative to open reduction and plate fixation. The major advantages are closed procedure and simplified interlocking techniques. Therefore, closed intramedullary nailing combined with covered screw fixation is a safe and effective method of managing this type of fracture.

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