TECHNICAL TRICK
Intramedullary Nailing of Tibial Shaft Fractures Distal to Total Knee Arthroplasty Justin M. Haller, MD,* Erik N. Kubiak, MD,* Andre Spiguel, MD,† Michael J. Gardner, MD,† and Daniel S. Horwitz, MD‡
Key Words: tibial fracture, total knee arthroplasty, intramedullary nail
impairment. In addition, inactivity in this patient population can lead to complications, including pneumonia, venous thromboembolic disease, pressure ulcers, and dementia. We describe techniques for intramedullary nailing (IMN) of tibial fractures below a TKA that does not disturb the tibial prosthesis component. We feel that these techniques offer the advantage of stable fixation while allowing early weight bearing in patients who are at increased risk of postoperative complications secondary to weight-bearing restrictions. The greatest challenges present when a wellfixed tibial tray is in place are the starting point, avoiding damage to the tibial component, and navigating wires, reamers, and a nail down the canal without damaging the TKA or causing cortical blowout.
(J Orthop Trauma 2014;28:e296–e300)
Technique
Summary: Tibial shaft fractures distal to total knee arthroplasty are rare, but they are likely to become more common with the increasing number of arthroplasty procedures being performed. These fracture patterns have been treated in the past either with closed reduction and casting/bracing or with open reduction internal fixation using plates. Weight-bearing precautions in the elderly patient population can affect patient disposition, and weight bearing on extramedullary fixation can lead to early hardware failure. We present a series of nailing techniques that can be used for tibial fractures distal to a wellfixed total knee arthroplasty that avoids the tibial baseplate, provides stable fracture fixation, and allows for early weight bearing.
INTRODUCTION In contrast to periprosthetic supracondylar femur fractures after a total knee arthroplasty (TKA), periprosthetic tibial fractures are rare. In a recent study of over 17,000 TKAs, the incidence of periprosthetic tibial fractures was reported to be 0.4%. In this same study, the incidence of fracture distal to a stable, well-fixed tibial implant was 0.09%.1 With increasing life expectancy and the functional demands of the elderly, the number of TKA procedures is expected to be more than double over the next decade.2 Likewise, the expected incidence of periprosthetic tibial fractures is likely to increase. These fractures are often complicated by poor bone stock and impaired healing potential, both of which can place additional stress on the implant. Diaphyseal tibial fractures distal to a well-fixed tibial component with a stable pattern and minimal displacement have been treated nonoperatively, whereas unstable displaced fractures are ideally treated with open reduction internal fixation.1,3,4 However, both treatment methods are associated with weight-bearing restrictions, which can be difficult for elderly patients with multiple comorbidities and balance
The primary unique elements of this technique include the following: 1. A more distal transpatellar tendinous approach, 2. Hand reaming of the proximal tibia, in proximity to the TKA, 3. Use of the Yankauer suction tip to guide the bulb-tipped wire pass the posterior cortex proximally, 4. Choice of small diameter nail (9 mm or less), and 5. Intraoperative bending of the tip of the nail using a bending press to allow the nail to pass the posterior cortex proximally.
TECHNIQUE
Accepted for publication March 13, 2014. From the *Department of Orthopaedics, University of Utah, Salt Lake City, UT; †Department of Orthopaedics, Washington University, St Louis, MO; and ‡Department of Orthopaedics, Geisinger Health System, Danville, PA. The authors report no conflict of interest. Reprints: Daniel S. Horwitz, MD, Department of Orthopaedics, Geisinger Health System, 100 North Academy Avenue, Danville, PA 17822-4910 (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
The patient is positioned supine on a radiolucent table, and the normal rotation of the patient’s contralateral leg is observed. A small bump is placed under the ipsilateral hip. The contralateral lower extremity is well padded and secured. The fluoroscopy unit is placed on the contralateral side, and the fluoroscopy monitor is positioned at the foot of the bed. The injured lower extremity is then prepped and draped in usual sterile fashion. Finding the correct starting point is crucial to allow the nail to pass the tibial tray of the TKA. A sterile radiolucent triangle may be placed under the knee to assist with flexion. The joint line and tibial tubercle are palpated and verified under fluoroscopy. A direct midline approach is chosen to avoid any deforming forces that would make gaining the starting point difficult. An incision is made over the distal half of the patella extending to approximately 1 cm distal to the tibial plateau. Sharp dissection proceeds through the dermis
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J Orthop Trauma Volume 28, Number 12, December 2014
| www.jorthotrauma.com
J Orthop Trauma Volume 28, Number 12, December 2014
Tibial Nailing Distal to TKA
FIGURE 1. Lateral fluoroscopic view demonstrating slightly more distal starting point.
FIGURE 3. Lateral fluoroscopic view of Yankauer suction tip placed in intramedullary canal.
down to epitenon, and the patellar tendon is sharply divided in line with the orientation of the fibers. A threaded guide wire is started slightly more distal than in a traditional nail so as to avoid the tibial tray, and positioning is verified with fluoroscopy (Fig. 1). An opening hand reamer or awl is then used to gain access to the medullary canal (Fig. 2). The canal is decompressed with suction, and a Yankauer suction tip is left in place to guide the wire pass the flange of
the tibial component (Figs. 3, 4). In patients with severe osteopenia, the Yankauer tip also assists in guiding the wire down the medullary canal and helps to avoid violating the posterior cortex because of the obliquity and rigidity of the guide wire (Fig. 5). Manual traction and manipulation are used to obtain satisfactory fracture reduction as the balltipped wire is passed distally in the diaphysis and into the distal segment. Fluoroscopy is used to verify positioning of the wire on both anterior–posterior (AP) and lateral views. Sequential hand reamers are used to open the proximal aspect of the canal as power reaming could open the proximal hole more than is desired and could potentially loosen the tibial baseplate. Power reaming is performed at the fracture site and in the distal tibia. After reaming achieves adequate
FIGURE 2. Lateral fluoroscopic view using opening cannulated awl.
FIGURE 4. Yankauer suction tip used to assist passing the guide wire and hand reamers.
Ó 2014 Lippincott Williams & Wilkins
www.jorthotrauma.com |
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Haller et al
J Orthop Trauma Volume 28, Number 12, December 2014
used to visualize the nail during advancement and verify that the tip of the nail avoids the posterior cortex. Final position is verified with fluoroscopy on AP and lateral views. Proximal and distal interlocks are placed, and AP and lateral views are obtained with fluoroscopy. In the severely osteopenic patient, angular stable interlocks can be used to increase overall stability and prevent distal screw back out, which can occur with minor construct motion in the setting of poor bone quality. After the nail has been locked, the nail insertion point is copiously irrigated to remove reamer debris. The fibers of the patellar tendon are re-approximated with 2-0 absorbable suture, and the dermis and skin are closed according to surgeon preference.
Clinical Experience
FIGURE 5. Lateral fluoroscopic view of Yankauer suction tip guiding passage of guide wire.
Between 2008 and 2012, 4 patients with acute tibial shaft fractures distal to a TKA were treated with IMN. Average patient age was 75.5 years (range, 65–83 years), and all patients were females. All the patients treated in this series sustained fracture of distal tibial diaphysis, OTA classification 42-B1, after a ground-level fall. Three of the 4 patients had an associated fibula fracture. There were no complications intraoperatively, and all nailing procedures were completed uneventfully. There were no infections, fixation failures, or nonunions postoperatively. All patients healed their fractures by their 6-month follow-up appointments, and there were no new symptoms relative to the TKA that could be attributed to the tibial nailing procedure. At the time of final follow-up (mean 14.3 months, range, 12–18 months), all patients had returned to their baseline level of function.
cortical contact, a nail of appropriate small diameter (9 mm diameter or less) and length is selected. Because of the positioning of the starting point and the proximal reamed tract, which are necessary to avoid the TKA, the tip of the nail may abut the posterior cortex (Fig. 6). Consequently, a tabletop bender can be used to put a more distal bend in the nail to avoid violating the posterior cortex. Fluoroscopy should be
Case Example
FIGURE 6. Lateral fluoroscopic view of intramedullary nail abutting the posterior cortex.
Although diaphyseal tibial fractures distal to a wellfixed TKA are rare, the incidence is likely to increase over the next decade. Treatment of a diaphyseal tibial fracture with a stable TKA can be with external fixation, IMN, or plating or nonoperative. External fixation is rarely used definitively as it is associated with pin tract infections and increased incidence
A 76-year-old woman presented with medical history significant for rheumatoid arthritis and a cerebrovascular accident with right-sided weakness leading to frequent falls. She sustained a ground-level fall and presented to the emergency department with pain and obvious deformity of her right lower extremity. Plain radiographs of the right tibia and fibula demonstrate a fracture of the distal tibial diaphysis consistent with OTA classification 42-B1.2 (Fig. 7). Radiographic imaging of her right knee showed a well-fixed tibial component with no signs of loosening or failure. After she was medically cleared, the patient was taken to the operating room for the above-described procedure. Her postoperative hospital course was unremarkable, and the patient was discharged home on postoperative day 5. She was made weight bearing as tolerated immediately. By the 16-week clinic visit, she had no pain at the fracture site and had returned to her baseline ambulation status. She continued to do well at the 12-month follow-up visit (Fig. 8).
DISCUSSION
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Ó 2014 Lippincott Williams & Wilkins
J Orthop Trauma Volume 28, Number 12, December 2014
FIGURE 7. Preoperative AP radiograph.
of malunion and nonunion, especially in the osteopenic patient.5 Nonoperative management of tibial fractures is an option in axially stable fractures with minimal shortening.6 Poor bone quality, peripheral vascular disease, smoking, diabetes, and limited pre-injury mobility can lead to worse patient outcomes.5,7 Nonoperative treatment consists of either an above-knee cast for 2 weeks followed by a functional brace or an above-knee cast for the duration of treatment.
Tibial Nailing Distal to TKA
An intact fibula is a relative contraindication to using a functional brace because it is associated with increased risk of angular deformity.8 In the presented case example, nonoperative treatment would have required this patient to be in an above-knee cast for over 4 months.6 With her preexisting weakness and poor balance, this option would likely have resulted in limited ambulation and prolonged recovery. Open reduction with plate fixation remains a reasonable option for treating a distal diaphyseal tibial fracture. Plates have been shown to have less incidence of malunion or nonunion when compared with nails when treating these injuries, but poor quality cortical bone in osteoporotic patients makes plate fixation less reliable.9 Although some studies have shown nails to have lower infection rates than plates, a recent prospective randomized study found no difference in infection rates.9–11 Additionally, plate fixation requires restricted weight bearing until union is achieved. Because of concerns of the restricted weight bearing and poor soft tissues in the presented patient, it was felt that plate fixation was not the optimal treatment for her. In the setting of severe osteopenia and poor balance, an intramedullary nail was the preferred treatment. The nail allows for early weight bearing while preserving the soft tissues around the fracture site.12–15 Modern tibial nail designs allow for multiple interlock screws to be placed in the distal fragment to provide better rotational control.16,17 Additionally, using angular stable distal interlock screws may decrease screw cutout in osteopenic patients. In studies comparing IMN and casting, higher rates of delayed union and malunion, limited ankle range of motion, and worse patient outcome scores are reported in the casting group.18,19 Treatment with IMN allowed this patient to be discharged home without complications, where she was able to ambulate with a walker. Other authors have suggested the use of an intramedullary implant placed through a different starting point. Doulens et al20 placed a standard intramedullary nail in a retrograde fashion using the medial malleolus as the starting point. Placement of the nail through this entry point resulted
FIGURE 8. Postoperative AP radiograph. Ó 2014 Lippincott Williams & Wilkins
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J Orthop Trauma Volume 28, Number 12, December 2014
in iatrogenic fracture that was subsequently fixed. ZafraJimenez et al21 used a retrograde hindfoot nail to treat a distal diaphyseal tibial fracture below a TKA with good results. However, this procedure requires the implant to be removed after fracture union because of limited ankle and subtalar motion and the potential stress riser created between the tip of the nail and the TKA implant. The techniques we describe greatly assist with the anterograde nailing of these types of fractures. All the patients treated in this series sustained distal tibial fracture, and 3 of 4 had associated fibula fracture. We recommend that this technique be used primarily for this fracture pattern distal to a TKA as opposed to a fracture just distal to the tibial tray. The anterior starting point would make treatment of these more proximal fractures more difficult. The use of the Yankauer tip to pass the wire and avoid posterior cortical disruption is a useful technique in the extremely osteoporotic patient. In addition, the use of a small diameter nail and the custom anterior bend placed on the nail both allow it to navigate the significant bend created by the distal and anterior starting point required when a tibial tray is in place. Advances in the hardware used in arthroplasty and fracture fixation permit nailing of tibial fractures with ipsilateral TKA in the appropriate patient. Tibial component design, fracture pattern, and patient characteristics must be considered when deciding on treatment options. To the best of our knowledge, there has been no previous study describing the technique used to place a tibial IMN with ipsilateral TKA. We propose the above technique as a viable option for the treatment of these currently rare but difficult to treat fractures.
6. Sarmiento A, Latta LL. 450 closed fractures of the distal third of the tibia treated with a functional brace. Clin Orthop Relat Res. 2004;428: 261–271. 7. Lemon M, Somayaji HS, Khaleel A, et al. Fragility fractures of the ankle: stabilization with an expandable calcaneotalotibial nail. J Bone Joint Surg Br. 2005;87:809–813. 8. Sarmiento A, Sharpe FE, Ebramzadeh E, et al. Factors influencing the outcome of closed tibial fractures treated with functional bracing. Clin Orthop Relat Res. 1995;315:8–24. 9. Vallier HA, Cureton BA, Patterson BM. Randomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fracture. J Orthop Trauma. 2011;25:736–741. 10. Borg T, Larsson S, Lindsjo U. Percutaneous plating of distal tibial fractures. Preliminary results in 21 patients. Injury. 2004;35:608–614. 11. Guo JJ, Tang N, Yang HL, et al. A prospective, randomized trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. J Bone Joint Surg Br. 2010;92-B:984–988. 12. Blachut PA, O’Brien PJ, Meek RN, et al. Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft: a prospective, randomized study. J Bone Joint Surg Am. 1997;79:640–646. 13. Finkemeier CG, Schmidt AH, Kyle RF, et al. A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma. 2000;14:187–193. 14. Keating JF, O’Brien PJ, Blachut PA, et al. Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft: a prospective, randomized study. J Bone Joint Surg Am. 1997;79:334–341. 15. Robinson CM, McLauchlan GJ, McLean IP, et al. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle: classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br. 1995;77:781–787. 16. Henley MB, Meier M, Tencer AF. Influences of some design parameters on the biomechanics of the unreamed tibial intramedullary nail. J Orthop Trauma. 1993;7:311–319. 17. Drosos G, Karnezis IA, Bishay M, et al. Initial rotational stability of distal tibial fractures nailed without proximal locking: the importance of fracture type and degree of cortical contact. Injury. 2001;32:137–143. 18. Karladani AH, Granhed H, Edshage B, et al. Displaced tibial shaft fractures: a prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients. Acta Orthop Scand. 2000;71:160– 167. 19. Bone LB, Sucato D, Stegemann PM, et al. Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. J Bone Joint Surg Am. 1997;79-A:1336–1341. 20. Doulens KM, Joshi AB, Wagner RA. Tibial fracture after total knee arthroplasty treated with retrograde intramedullary fixation. Am J Orthop. 2007;36:E111–E113. 21. Zafra-Jimenez JA, Pretell-Mazzini J, Resines-Erasun C. Distal tibial fracture below a total knee arthroplasty: retrograde intramedullary nailing as an alternative method of treatment: a case report. J Orthop Trauma. 2011;25:e74–e76.
REFERENCES 1. Felix NA, Stuart MJ, Hanssen AD. Periprosthetic fractures of the tibia associated with total knee arthroplasty. Clin Orthop Relat Res. 1997;345: 113–124. 2. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005-2030. J Bone Joint Surg Am. 2007;89:780–785. 3. Hanssen AD, Stuart MJ. Treatment of periprosthetic tibial fractures. Clin Orthop Relat Res. 2000;380:91–98. 4. Banim RH, Fletcher M, Warren P. Use of Dall-Miles plate and cables for the fixation of periprosthetic tibial fracture. J Arthroplasty. 2000;15:131–133. 5. Bedi A, Toan Le T, Karunakar M. Surgical treatment of nonarticular distal tibia fractures. J Am Acad Orthop Surg. 2006;14:406–414.
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Intramedullary Nailing of Tibial Shaft Fractures Distal to Total Knee Arthroplasty Justin M. Haller, MD,* Erik N. Kubiak, MD,* Andre Spiguel, MD,† Michael J. Gardner, MD,† and Daniel S. Horwitz, MD‡
Key Words: tibial fracture, total knee arthroplasty, intramedullary nail
impairment. In addition, inactivity in this patient population can lead to complications, including pneumonia, venous thromboembolic disease, pressure ulcers, and dementia. We describe techniques for intramedullary nailing (IMN) of tibial fractures below a TKA that does not disturb the tibial prosthesis component. We feel that these techniques offer the advantage of stable fixation while allowing early weight bearing in patients who are at increased risk of postoperative complications secondary to weight-bearing restrictions. The greatest challenges present when a wellfixed tibial tray is in place are the starting point, avoiding damage to the tibial component, and navigating wires, reamers, and a nail down the canal without damaging the TKA or causing cortical blowout.
(J Orthop Trauma 2014;28:e296–e300)
Technique
Summary: Tibial shaft fractures distal to total knee arthroplasty are rare, but they are likely to become more common with the increasing number of arthroplasty procedures being performed. These fracture patterns have been treated in the past either with closed reduction and casting/bracing or with open reduction internal fixation using plates. Weight-bearing precautions in the elderly patient population can affect patient disposition, and weight bearing on extramedullary fixation can lead to early hardware failure. We present a series of nailing techniques that can be used for tibial fractures distal to a wellfixed total knee arthroplasty that avoids the tibial baseplate, provides stable fracture fixation, and allows for early weight bearing.
INTRODUCTION In contrast to periprosthetic supracondylar femur fractures after a total knee arthroplasty (TKA), periprosthetic tibial fractures are rare. In a recent study of over 17,000 TKAs, the incidence of periprosthetic tibial fractures was reported to be 0.4%. In this same study, the incidence of fracture distal to a stable, well-fixed tibial implant was 0.09%.1 With increasing life expectancy and the functional demands of the elderly, the number of TKA procedures is expected to be more than double over the next decade.2 Likewise, the expected incidence of periprosthetic tibial fractures is likely to increase. These fractures are often complicated by poor bone stock and impaired healing potential, both of which can place additional stress on the implant. Diaphyseal tibial fractures distal to a well-fixed tibial component with a stable pattern and minimal displacement have been treated nonoperatively, whereas unstable displaced fractures are ideally treated with open reduction internal fixation.1,3,4 However, both treatment methods are associated with weight-bearing restrictions, which can be difficult for elderly patients with multiple comorbidities and balance
The primary unique elements of this technique include the following: 1. A more distal transpatellar tendinous approach, 2. Hand reaming of the proximal tibia, in proximity to the TKA, 3. Use of the Yankauer suction tip to guide the bulb-tipped wire pass the posterior cortex proximally, 4. Choice of small diameter nail (9 mm or less), and 5. Intraoperative bending of the tip of the nail using a bending press to allow the nail to pass the posterior cortex proximally.
TECHNIQUE
Accepted for publication March 13, 2014. From the *Department of Orthopaedics, University of Utah, Salt Lake City, UT; †Department of Orthopaedics, Washington University, St Louis, MO; and ‡Department of Orthopaedics, Geisinger Health System, Danville, PA. The authors report no conflict of interest. Reprints: Daniel S. Horwitz, MD, Department of Orthopaedics, Geisinger Health System, 100 North Academy Avenue, Danville, PA 17822-4910 (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
The patient is positioned supine on a radiolucent table, and the normal rotation of the patient’s contralateral leg is observed. A small bump is placed under the ipsilateral hip. The contralateral lower extremity is well padded and secured. The fluoroscopy unit is placed on the contralateral side, and the fluoroscopy monitor is positioned at the foot of the bed. The injured lower extremity is then prepped and draped in usual sterile fashion. Finding the correct starting point is crucial to allow the nail to pass the tibial tray of the TKA. A sterile radiolucent triangle may be placed under the knee to assist with flexion. The joint line and tibial tubercle are palpated and verified under fluoroscopy. A direct midline approach is chosen to avoid any deforming forces that would make gaining the starting point difficult. An incision is made over the distal half of the patella extending to approximately 1 cm distal to the tibial plateau. Sharp dissection proceeds through the dermis
e296
J Orthop Trauma Volume 28, Number 12, December 2014
| www.jorthotrauma.com
J Orthop Trauma Volume 28, Number 12, December 2014
Tibial Nailing Distal to TKA
FIGURE 1. Lateral fluoroscopic view demonstrating slightly more distal starting point.
FIGURE 3. Lateral fluoroscopic view of Yankauer suction tip placed in intramedullary canal.
down to epitenon, and the patellar tendon is sharply divided in line with the orientation of the fibers. A threaded guide wire is started slightly more distal than in a traditional nail so as to avoid the tibial tray, and positioning is verified with fluoroscopy (Fig. 1). An opening hand reamer or awl is then used to gain access to the medullary canal (Fig. 2). The canal is decompressed with suction, and a Yankauer suction tip is left in place to guide the wire pass the flange of
the tibial component (Figs. 3, 4). In patients with severe osteopenia, the Yankauer tip also assists in guiding the wire down the medullary canal and helps to avoid violating the posterior cortex because of the obliquity and rigidity of the guide wire (Fig. 5). Manual traction and manipulation are used to obtain satisfactory fracture reduction as the balltipped wire is passed distally in the diaphysis and into the distal segment. Fluoroscopy is used to verify positioning of the wire on both anterior–posterior (AP) and lateral views. Sequential hand reamers are used to open the proximal aspect of the canal as power reaming could open the proximal hole more than is desired and could potentially loosen the tibial baseplate. Power reaming is performed at the fracture site and in the distal tibia. After reaming achieves adequate
FIGURE 2. Lateral fluoroscopic view using opening cannulated awl.
FIGURE 4. Yankauer suction tip used to assist passing the guide wire and hand reamers.
Ó 2014 Lippincott Williams & Wilkins
www.jorthotrauma.com |
e297
Haller et al
J Orthop Trauma Volume 28, Number 12, December 2014
used to visualize the nail during advancement and verify that the tip of the nail avoids the posterior cortex. Final position is verified with fluoroscopy on AP and lateral views. Proximal and distal interlocks are placed, and AP and lateral views are obtained with fluoroscopy. In the severely osteopenic patient, angular stable interlocks can be used to increase overall stability and prevent distal screw back out, which can occur with minor construct motion in the setting of poor bone quality. After the nail has been locked, the nail insertion point is copiously irrigated to remove reamer debris. The fibers of the patellar tendon are re-approximated with 2-0 absorbable suture, and the dermis and skin are closed according to surgeon preference.
Clinical Experience
FIGURE 5. Lateral fluoroscopic view of Yankauer suction tip guiding passage of guide wire.
Between 2008 and 2012, 4 patients with acute tibial shaft fractures distal to a TKA were treated with IMN. Average patient age was 75.5 years (range, 65–83 years), and all patients were females. All the patients treated in this series sustained fracture of distal tibial diaphysis, OTA classification 42-B1, after a ground-level fall. Three of the 4 patients had an associated fibula fracture. There were no complications intraoperatively, and all nailing procedures were completed uneventfully. There were no infections, fixation failures, or nonunions postoperatively. All patients healed their fractures by their 6-month follow-up appointments, and there were no new symptoms relative to the TKA that could be attributed to the tibial nailing procedure. At the time of final follow-up (mean 14.3 months, range, 12–18 months), all patients had returned to their baseline level of function.
cortical contact, a nail of appropriate small diameter (9 mm diameter or less) and length is selected. Because of the positioning of the starting point and the proximal reamed tract, which are necessary to avoid the TKA, the tip of the nail may abut the posterior cortex (Fig. 6). Consequently, a tabletop bender can be used to put a more distal bend in the nail to avoid violating the posterior cortex. Fluoroscopy should be
Case Example
FIGURE 6. Lateral fluoroscopic view of intramedullary nail abutting the posterior cortex.
Although diaphyseal tibial fractures distal to a wellfixed TKA are rare, the incidence is likely to increase over the next decade. Treatment of a diaphyseal tibial fracture with a stable TKA can be with external fixation, IMN, or plating or nonoperative. External fixation is rarely used definitively as it is associated with pin tract infections and increased incidence
A 76-year-old woman presented with medical history significant for rheumatoid arthritis and a cerebrovascular accident with right-sided weakness leading to frequent falls. She sustained a ground-level fall and presented to the emergency department with pain and obvious deformity of her right lower extremity. Plain radiographs of the right tibia and fibula demonstrate a fracture of the distal tibial diaphysis consistent with OTA classification 42-B1.2 (Fig. 7). Radiographic imaging of her right knee showed a well-fixed tibial component with no signs of loosening or failure. After she was medically cleared, the patient was taken to the operating room for the above-described procedure. Her postoperative hospital course was unremarkable, and the patient was discharged home on postoperative day 5. She was made weight bearing as tolerated immediately. By the 16-week clinic visit, she had no pain at the fracture site and had returned to her baseline ambulation status. She continued to do well at the 12-month follow-up visit (Fig. 8).
DISCUSSION
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| www.jorthotrauma.com
Ó 2014 Lippincott Williams & Wilkins
J Orthop Trauma Volume 28, Number 12, December 2014
FIGURE 7. Preoperative AP radiograph.
of malunion and nonunion, especially in the osteopenic patient.5 Nonoperative management of tibial fractures is an option in axially stable fractures with minimal shortening.6 Poor bone quality, peripheral vascular disease, smoking, diabetes, and limited pre-injury mobility can lead to worse patient outcomes.5,7 Nonoperative treatment consists of either an above-knee cast for 2 weeks followed by a functional brace or an above-knee cast for the duration of treatment.
Tibial Nailing Distal to TKA
An intact fibula is a relative contraindication to using a functional brace because it is associated with increased risk of angular deformity.8 In the presented case example, nonoperative treatment would have required this patient to be in an above-knee cast for over 4 months.6 With her preexisting weakness and poor balance, this option would likely have resulted in limited ambulation and prolonged recovery. Open reduction with plate fixation remains a reasonable option for treating a distal diaphyseal tibial fracture. Plates have been shown to have less incidence of malunion or nonunion when compared with nails when treating these injuries, but poor quality cortical bone in osteoporotic patients makes plate fixation less reliable.9 Although some studies have shown nails to have lower infection rates than plates, a recent prospective randomized study found no difference in infection rates.9–11 Additionally, plate fixation requires restricted weight bearing until union is achieved. Because of concerns of the restricted weight bearing and poor soft tissues in the presented patient, it was felt that plate fixation was not the optimal treatment for her. In the setting of severe osteopenia and poor balance, an intramedullary nail was the preferred treatment. The nail allows for early weight bearing while preserving the soft tissues around the fracture site.12–15 Modern tibial nail designs allow for multiple interlock screws to be placed in the distal fragment to provide better rotational control.16,17 Additionally, using angular stable distal interlock screws may decrease screw cutout in osteopenic patients. In studies comparing IMN and casting, higher rates of delayed union and malunion, limited ankle range of motion, and worse patient outcome scores are reported in the casting group.18,19 Treatment with IMN allowed this patient to be discharged home without complications, where she was able to ambulate with a walker. Other authors have suggested the use of an intramedullary implant placed through a different starting point. Doulens et al20 placed a standard intramedullary nail in a retrograde fashion using the medial malleolus as the starting point. Placement of the nail through this entry point resulted
FIGURE 8. Postoperative AP radiograph. Ó 2014 Lippincott Williams & Wilkins
www.jorthotrauma.com |
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Haller et al
J Orthop Trauma Volume 28, Number 12, December 2014
in iatrogenic fracture that was subsequently fixed. ZafraJimenez et al21 used a retrograde hindfoot nail to treat a distal diaphyseal tibial fracture below a TKA with good results. However, this procedure requires the implant to be removed after fracture union because of limited ankle and subtalar motion and the potential stress riser created between the tip of the nail and the TKA implant. The techniques we describe greatly assist with the anterograde nailing of these types of fractures. All the patients treated in this series sustained distal tibial fracture, and 3 of 4 had associated fibula fracture. We recommend that this technique be used primarily for this fracture pattern distal to a TKA as opposed to a fracture just distal to the tibial tray. The anterior starting point would make treatment of these more proximal fractures more difficult. The use of the Yankauer tip to pass the wire and avoid posterior cortical disruption is a useful technique in the extremely osteoporotic patient. In addition, the use of a small diameter nail and the custom anterior bend placed on the nail both allow it to navigate the significant bend created by the distal and anterior starting point required when a tibial tray is in place. Advances in the hardware used in arthroplasty and fracture fixation permit nailing of tibial fractures with ipsilateral TKA in the appropriate patient. Tibial component design, fracture pattern, and patient characteristics must be considered when deciding on treatment options. To the best of our knowledge, there has been no previous study describing the technique used to place a tibial IMN with ipsilateral TKA. We propose the above technique as a viable option for the treatment of these currently rare but difficult to treat fractures.
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