Distal quarter leg fractures fixation: The intramedullary nailing alone option

M Ehlinger, P Adam, A Gabrion, L Jeunet, F Dujardin, G Asencio
Orthopaedics & Traumatology, Surgery & Research: OTSR 2010, 96 (6): 674-82

INTRODUCTION: Intramedullary (IM) nailing is the classical treatment for diaphyseal fractures of the tibia. Stabilizing fractures of the distal quarter is recognized as being delicate. We report a continuous, multicenter prospective study of distal tibia-fibula fractures treated with anterograde intramedullary nailing.

HYPOTHESIS: The working hypothesis was to identify the problems encountered with IM nailing alone of distal leg fractures.

PATIENTS AND METHODS: From May 2007 to November 2008, 51 fractures in 51 patients (19 females and 32 males; mean age, 46.2 years [range, 17-93 years]) were treated with IM nailing. The fractures were classified according to the association pour l'ostéosynthèse (AO) classification, with most type A1 (29/51). Thirteen fractures presented a distal articular extension treated with screws in five cases. Fixation consisted in intramedullary nailing, reamed in all cases, performed on a standard or orthopaedic surgery table. Nailing was static and distally locked (50/51). The patients were evaluated clinically and radiologically, with AP and lateral images of both legs and the Olerud score.

RESULTS: We report one death and eight patients lost to follow-up, providing 42 cases to reviewing at 1 year. The bone union rate was 97.6% in a mean 15.7 weeks. Immediately after surgery, 14 axial deviations greater than 5° were observed, mainly valgus, with only one greater than 10°. The absence of fibular fixation was the only identifiable risk factor for appearance of an initial axial deviation as well as fracture instability over time. Two infections were observed and at 6 months four secondary displacements, one of which can be explained by changing the distal locking due to infection. Four dynamizations were performed. No other risk factor was found. The mean Olerud functional score at 12 months was 83.5 points.

DISCUSSION: The clinical results are comparable to those reported in the literature. From a radiological point of view, the rates and times to bone union were identical. However, the rates of malunion were clearly higher. The risk factors for malunion found in the literature are metaphyseal enlargement, fracture comminution, a too distal location of fracture site, young patient age, patient installation on a standard operating table, and technical errors. The absence of supplementary fibular fixation, the subject of debate in the literature, was the only statistically significant point found in the present study. Nailing distal fractures of the leg provides good clinical results. However, with regard to the malunion rates, the technique must be precise and rigorous. We recommend systematic fibular fixation and use of an orthopaedic table.

LEVEL OF EVIDENCE: Level IV; cohort type prospective study.

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