Intramedullary Osteosynthesis of Metadiaphyseal Proximal Tibial Fractures: An Optimized Implant Geometry Can Help to Solve the Problem

Abstract

Aim: The surgical treatment of proximal tibial fractures by means of intramedullary nailing was considered as clinically critical and biomechanically unsatisfactory. A solution for the treatment of these fractures was intended by optimizing the geometry of a newly developed Proximal Tibial Nail (PTN).
Material and Methods: After analysis of mechanisms and causes of failures of osteosyntheses of proximal tibial fractures, new nail geometries were developed and their specific performance analysed. The optimised new PTN was implanted in 43 patients with a proximal or a combined proximal and shaft fracture of the tibia in a prospective documentation series. The complete clinical and radiological data of all patients was collected. A biomechanical comparative study between PTN and conventional osteosyntheses (Double Plate Osteosynthesis=DPO and External Fixator=EF) was performed.
Results: During the whole documentation phase no implant related complication led to operative revision. One deep wound infection after treatment of a II° open fracture occurred. Sequential revisions and exchanging of the nail to another PTN had to be performed. Secondary displacement of the proximal fracture fragment was seen in one case and breakage of the proximal locking screws after early postoperative full weight bearing in another. For the axial loading, the values for the PTN and DPO were 372 N/mm and 155 N/mm at 350 N. This was much higher than that of ExFix compared to PTN with 64 N/mm and 421 N/mm respectively.
Conclusion: The new PTN makes a stable fixation of proximal tibia fractures possible which is superior to DPO and EF for the relevant axial loading condition. The proven biomechanical superiority of intramedullary nailing in shaft fractures can also be used in proximal tibial fractures. The clinical results are promising but require further prospective evaluation.

Proximal fracture - Tibia - Nail

References

• 1 Bolhofner B R. Indirect reduction and composite fixation of extraarticular proximal tibia fractures.  Clin Orthop. 1995;  315 75-83
• 2 Buehler K C, Green J, Woll T S, Duwelius P J. A technique for intramedullary nailing of proximal third tibia fractures.  J Orthop Trauma. 1997;  11 (3) 218-223
• 3 Burstein A H, Wright T M. Mechanische Verhalten von Skelettstrukturen. In: Biomechanik in Orthopädie und Traumatologie, Thieme Verlag, Stuttgart, New York 1997; pp 103-106
• 4 Cole J D. Intramedullary fixation of proximal tibia fractures.  Techniques in orthopaedics. 1998;  13 (1) 27-37
• 5 Eingartner C, Schuler F, Müller C A, Schreitmüller E, Schneider E, Weise K. Kombinationsverfahren sind zur Stabilisierung proximaler Tibiaschaftfrakturen besser geeignet als die alleinige Marknagelung.  Eur J Trauma (Suppl.). 2002;  1 101
• 6 Freedman E L, Johnson E E. Radiographic analysis of tibia fracture malalignment following intramedullary nailing.  Clin Orthop. 1995;  315 25-33
• 7 Gustilo R B, Anderson J T. Prevention of Infection in the treatment of one thousand and twenty-five open fractures of long bones: a retrospective and prospective analysis.  J Bone Joint Surg. 1976;  58 453-458
• 8 Hansen M, Gercek E, Blum J, Rommens P M. Osteosynthetische Versorgung proximaler extraartikulärer Tibiafrakturen - Indikationen, Komplikationen, Ergebnisse.  Unfallchirurgie. 1999;  25 (3-4) 174-182
• 9 Krettek C, Miclau T, Schandelmeier P, Stephan C, Möhlmann U, Tscherne H. The mechanical effect of blocking screws (”Poller screws”) in stabilising tibia fractures with short proximal or distal fragments after insertion of small diameter intramedullary nails.  J Orthop Trauma. 1999;  13 (8) 550-553
• 10 Lang G J, Cohen B E, Bosse M J, Kellam J F. Proximal third tibia fractures - should they be nailed?.  Clin Orthop. 1995;  315 64-74
• 11 Müller M E, Allgöwer M, Schneider R, Willenegger H. Manual der Osteosynthese. AO-Technik. Springer Verlag, Berlin, Heidelberg, New York 1992
• 12 Oestern H J, Tscherne H. Pathophysiology and classification of soft tissue injuries associated with fractures. In: Tscherne H, Gotzen L (eds). Fractures with soft tissue injuries, Springer Verlag, Berlin 1984
• 13 Pfister U. Intramedulläre Stabilisierungsverfahren bei Tibiafrakturen: State of the Art.  OP-Journal. 2000;  16 176-180
• 14 Ries M D, Meinhard B P. Medial external fixation with lateral plate internal fixation in metaphyseal tibia fractures.  Clin Orthop. 1990;  256 215-223
• 15 Schandelmeier P, Krettek C, Tscherne H. Biomechanische Untersuchungen von 9 Tibiaverriegelungsnägeln im Knochen-Implantat-Verbund.  Unfallchirurg. 1994;  97 600-608
• 16 Europäischer Unfallkongress .Trauma. 2000, 10. -13. September 2000, Hannover
• 17 Schütz M, Raschke M, Hoffmann R. Die zusätzliche Applikation eines AO Zangenfixateurs erhöht die Primärstabilität nach unaufgebohrter Marknagelung proximaler Tibiafrakturen - Eine biomechanische Kadaverstudie.  Hefte zu der Unfallchirurg. 1997;  268 779-782
• 18 Wagner H E, Jakob R P. Zur Problematik der Plattenosteosynthese bei den bikondylären Tibiakopffrakturen.  Unfallchirurg. 1986;  89 304-311
• 19 Watson J T. Tibia: proximal. In: Rüedi TP, Murphy WM (Hrsg). AO Principles of fracture management. Georg Thieme Verlag, Stuttgart, New York 2000