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INTRODUCTION: The distal tibial nail (DTN) is a novel retrograde intramedullary nail used for distal tibial fracture stabilization. We investigated the clinical results of DTN use for distal tibial fractures and compared them with those reported in the literature on locking plates and antegrade intramedullary nails. MATERIALS AND METHODS: This multicenter, prospective, observational cohort study examined distal tibial fractures with AO/OTA classification 43 types: A1, A2, A3 or C1. The primary outcomes included bone union rate, soft tissue problems, and surgical complications. Secondary outcomes were EuroQol-5 Dimension-5 Level (EQ-5D-5L), Self-Administered Foot Evaluation Questionnaire (SAFE-Q), and American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot clinical scores 1 year postoperatively. Incidence of varus or valgus/anterior-posterior flexion deformity with a difference of ≥5° and postoperative reduction loss rate were evaluated. RESULTS: Five men and five women were enrolled (mean age, 69 years [range, 30-77 years]), including one open-fracture-type Gustilo type IIIB case. Bone union was observed in all patients at 6 months postoperatively. Delayed union, leg edema, and guide pin breakage were observed in three, one, and one cases, respectively. No soft tissue or surgical complications were observed. During the final follow-up, the EQ-5D-5L, SAFE-Q, and AOFAS hindfoot scores were 0.876 (0.665-1.0), 83-92, and AOFAS 92.6 (76-100), respectively. Varus and retroflexion deformities were observed in one case each. DISCUSSION: DTN has been reported to have biomechanically equivalent or stronger fixation strength than locking plates or antegrade intramedullary nails. In addition, while DTN was thought to be less invasive for soft tissue and can avoid injury to the knee, it was thought that care should be taken to avoid medial malleolus fractures and posterior tibialis tendon injuries. Comparisons with literature treatment results for locking plates and antegrade intramedullary nails showed comparable to advantageous results. CONCLUSIONS: DTN treatment results for distal tibial fractures were as good as those for locking plates and antegrade intramedullary nails. DTN is useful for stabilization and does not compromise the surrounding soft tissues.

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BACKGROUND: Type C3 distal tibial plafond fractures consistently show poor outcomes with high complication rates and significant risk of posttraumatic arthritis. We describe a minimally invasive technique of performing a primary ankle fusion using an anterograde tibial nail and compare our early results to traditional methods of fixation. METHODS: During the acute admission, the patient undergoes an arthroscopic preparation of the ankle joint and insertion of an anterograde nail into the talus. This technique is described in detail and presented alongside a retrospective 5-year review of all adult C3 distal tibial plafond fractures from our center. RESULTS: Twenty-six patients (8 open fractures) had been fixed traditionally using open reduction internal fixation (24 patients) and circular frames (2 patients) with an average follow-up of 20 months. Those internally fixed had protected weightbearing for 3 months. Complications included deep infection (12%), nonunion (8%), malunion (4%), severe posttraumatic osteoarthritis (27%), and the secondary conversion to ankle replacement/fusion (12%) requiring an average of 3 reoperations.Six patients underwent primary fusion (3 open fractures) with an average follow-up of 18 months. Patients were allowed to immediately weightbear. There were no reported complications and the primary fusion group demonstrated shorter hospital stays, faster return to work, and higher mean self-reported foot and ankle score (SEFAS) compared to those treated with ORIF. CONCLUSION: C3 distal tibial plafond fractures are difficult to manage and there has not been a satisfactory method of treating them that allows early return to work, has a low risk of complications, and reduces the risk of posttraumatic tibiotalar arthritis.We present our initial results with a method that uses traditional arthroscopic techniques to prepare the tibiotalar joint together with minimally invasive anterograde tibiotalar nailing. In this initial report of a small group of patients, we found that surgery can be performed once the swelling has subsided after injury and that allowing weightbearing as tolerated did not appear to have a negative effect on initial outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

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OBJECTIVE: Although various methods have been identified for the appropriate tibial nail length, there are disadvantages such as extra time, radiation exposure, and additional cost. We aimed to predict the ideal length of the nail according to the patient's height and shoe size in the preoperative period to eliminate these disadvantages. MATERIALS AND METHODS: Between January 2018 and August 2023, the height and shoe size data of 71 patients who were diagnosed with tibial shaft fracture and had tibia intramedullary nail fixation were determined. A linear regression model was applied to the normally distributed data. The correlation coefficient between the variables was evaluated according to the Pearson correlation coefficient. RESULTS: While 1 1-centimeter (cm) increase in patient height causes an increase of 3.2 millimeters (mm) in nail length, it was found that it alone contributed by 89% to predicting the ideal nail length (p<0.001). An increase of 1 unit in shoe size (EU) causes an increase of 9 mm in nail length; its contribution to predicting the ideal nail length alone is 84% (p<0.001). In the evaluation of the patient's height and shoe size together, it was observed that they jointly contributed 91% to the accurate estimation of the nail length (p<0.001). CONCLUSION: It may be risky to determine the tibial nail length only by shoe size or the patient's height. However, the correlation between them is strong. Therefore, by estimating nail lengths before the operation, the ideal nail length can be found by making fewer fluoroscopy checks during the operation.

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AIM: This article describes the technique of tibiotalar nailing performed using an antegrade tibial nail for salvage of distal tibia and ankle fractures in elderly patients. MATERIALS AND METHODS: We report indications, surgical technique, and the clinical outcomes and complication rate in our series to date. A retrospective review was performed at our level 1 major trauma centre. Patient demographics, comorbidities, and 12-month post-operative course were collected. Fractures were classified using the OTA/AO and modified Gustilo-Anderson classification. Fifteen patients underwent the procedure. We present data with a minimum 12-month follow-up. The median age of the patients in this cohort was 83 years (range, 51-102). Five patients were diabetic. Six patients (6/15; 40%) presented with an open fracture. RESULTS: At final follow-up, fourteen patients reported painless walking and had returned to baseline activity. CONCLUSION: This technique may serve as a salvage procedure, with indications similar to those for tibio-talar-calcaneal arthrodesis. Indications would include non-constructible pilon fractures, comminuted intra-articular fractures in low-demand patients, or patients at high risk of wound complications. LEVEL OF CLINICAL EVIDENCE: 3.

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BACKGROUND: While previous research has addressed conversion arthroplasty scenarios, there is limited data on outcomes of staged or concurrent removal of intramedullary (IM) nails during total knee arthroplasty (TKA). Our study aimed to explore the association between the timing of IM nail removal and the incidence of periprosthetic joint infection (PJI), surgical site infection (SSI), manipulation under anesthesia (MUA), and aseptic revision at 90 days, 1 year, and 2 years after TKA when IM nail removal is performed in either a (1) staged or (2) concurrent manner. METHODS: We queried a national, all-payer database of all patients who underwent a primary TKA and hardware removal of an IM tibial nail. The group was separated into mutually exclusive cohorts with removal performed either (1) in a staged manner (n = 287) or (2) on the same day of TKA (n = 2,958). Surgical complications included the following: PJIs, SSIs, MUAs, and aseptic revisions. Surgical complications were collected at 90-day, 1 year, and 2-year time points. RESULTS: Patients who had staged nail removal before TKA demonstrated the highest incidence of PJI at 90 days, 1 year, and 2 years (13.9, 16.7, and 17.1%, respectively). Adjusted multivariate regression analyses demonstrated significantly higher odds of a PJI, SSI, and MUA at 90 days, 1 year, and 2 years for all patients who had staged nail removal TKA (P < .001). CONCLUSIONS: There was an observed association between concurrent IM nail removal and a decreased risk of PJI, SSI, and MUA when compared to patients who had nail removal in a staged fashion. However, this does not discount the utility of the staged approach, as it may be necessary for patients less tolerant to longer operative times.

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Background: The treatment of congenital curvatures (bowing) of the tibia still represents a challenging problem for all pediatric orthopedic surgeons because of its unpredictable course, especially if pseudoarthrosis occurs after a pathologic fracture of the tibia. Case presentation: We describe the case of a child affected by an isolated curvature of his left leg. The congenital malformation was discovered at birth and no other pathological clinical finding was present. The first x-ray showed the presence of a congenital curvature of the tibia of the antero-lateral type. He was born in another country (Romania) and when he first came to our clinical observation at the Orthopedic and Traumatology Department, Pediatric Hospital "Bambino Gesu'", Rome, the child was 14 months of age and had already started walking. Only a leg discrepancy of about 2 cm was present with consequent pelvis obliquity. At the beginning, we prescribed external lower limb orthoses and a simple shoe rise to prevent a tibial pathologic fracture and reduce pelvic obliquity. At periodical clinical follow-up visits and despite the external lower limb orthoses prescribed, a progressive worsening of the severe congenital tibial curvature was observed together with signs and symptoms, such as pain and limping, that suggested an objective "pre-fracture stage" of the tibial curvature; we decided to perform surgery. At the time of surgery, the child was three and a half years old. Surgery consisted of a double osteotomy, both of the fibula and of the tibia. Subtraction of the distal meta-diaphyseal portion of the fibula and tibial osteotomy in Correspondence: of the major anterolateral curvature. The tibial osteotomy was then stabilized by an internal Rush rod inserted proximally to the tibia under the cartilage growth plate and made it end inside the distal tibial epiphysis, crossing the distal tibial cartilage growth plate, preserving the ankle joint. Results: The patient had an immediately excellent outcome. The tibial osteotomy site healed perfectly. At periodical orthopedic follow-up visits, the child was found to be always better. No clinical significative evidence of growth disturbances, due to the Rush rod that crossed the distal tibial cartilage growth plate, were noted. X-rays showed that the Rush rod progressively migrated with tibial growth together with the tibial bone growth, always getting further away from the distal tibial cartilage growth plate. Moreover, even the leg-length discrepancy and the pelvic obliquity improved. After an eight-year follow up, the patient, now a young boy of 11 and a half years, has an excellent outcome. Conclusions: Our case report undoubtedly provides further important information for the treatment of these rare congenital disorders. In particular, it highlights the management of the "pre-fracture stage" in a severe congenital tibial antero-lateral curvature in a very young child and describes the surgical technique performed.

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PURPOSE: To report the statistical stability of prospective clinical trials evaluating the effect of intramedullary reaming on rates of non-union in tibial fractures through calculation of the fragility metrics for non-union rates and all other dichotomous outcomes. METHODS: Literature search was conducted for prospective clinical trials evaluating the effect of intramedullary reaming on non-union rates in tibial nailing. All dichotomous outcomes were extracted from the manuscripts. The fragility index (FI) and reverse fragility index (RFI) were calculated by determining the number of event reversals required for a statistically significant outcome to lose significance and vice-versa. The fragility quotient (FQ) and reverse fragility quotient (RFQ) were calculated by dividing the FI or RFI by the sample size, respectively. Outcomes were defined as "fragile" if the FI or RFI was found to be less than or equal to the number of patients lost to follow-up. RESULTS: Literature search identified 579 results which produced ten studies meeting the criteria for review. There were 111 outcomes identified for analysis, of which 89 (80%) exhibited statistical fragility. For reported outcomes across the studies the median and mean FI was 2, the median FQ was 0.019, the mean FQ was 0.030, the median RFI was 4, the mean RFI was 3.95, the median RFQ was 0.045, and the mean RFQ was 0.030. Four studies reported outcomes which were found to have an FI of 0. CONCLUSIONS: The studies evaluating the effect of intramedullary reaming on tibial nail fixation demonstrate considerable fragility. On average, two event reversals for significant findings, and four event reversals for insignificant findings are sufficient to alter statistical significance. LEVEL OF EVIDENCE: Level II, systematic review of Level I and Level II studies.

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Aim: Distal tibial injuries combining bone loss, articular destruction and infection can be treated through distraction osteogenesis combined with ankle fusion. Bone transport is not without complications. This study investigates our preliminary results using a retrograde prefabricated gentamicin-coated nail (ETN PROtect®) to treat complications after infected bone defects of the distal tibial were managed by ankle arthrodesis and distraction osteogenesis. Materials and methods: This is a retrospective case series study. All consecutive patients with bone transport complications after ankle arthrodesis and distraction osteogenesis who were subsequently operated on using a retrograde ETN PROtect® nail were analysed. The cases occurred between 2017 and 2020. The primary objective was to report on the resolution of the clinical problem and the risk of deep infection after nail implantation. Results: Five patients have included: two docking site non-unions, two regenerated bone fractures and one hypotrophic regenerated bone. These complications were resolved in all patients (5/5, 100%). A painless, stable and plantigrade ankle arthrodesis was achieved in all cases. No patient developed a local infection or required nail removal (mean follow-up: 35.2 months). The mean LEFS score was 46.8 ± 13.8 and the mean knee ROM was 112 ± 12.7°. All patients tolerated full weight-bearing. All patients were very satisfied with the procedure (mean SAPS score was 93.8 points). Conclusion: The staged retrograde nailing technique using the ETN PROtect® nail may represent an effective and safe treatment for bone transport complications in high-infection-risk patients. Furthermore, the technique allows simultaneous achievement of ankle arthrodesis. The patients had good functional outcomes and were satisfied with the procedure. Clinical significance: This strategy of using retrograde gentamicin-coated tibial nails offers a solution to resolve bone transport complications while simultaneously achieving functional ankle arthrodesis. How to cite this article: Pujol O, Vicente M, Castellanos S, et al. Preliminary Outcomes of a Staged Percutaneous Retrograde Prefabricated Gentamicin-coated Intramedullary Nail to Manage Complications after Ankle Fusion through Tibial Bone Transport. Strategies Trauma Limb Reconstr 2023;18(3):155-162.

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High-energy trauma of the lower leg can cause conditions such as bone defects, loss of the articular surface or a complex soft tissue injury. Given the type of the injury, as well as the often poor general status of the patient, the initial treatment usually consists of debridement and external fixation. The role of the retrograde calcaneo-talo-tibial nail is acknowledged in the treatment of post-traumatic arthritis of the talocrural joint, rheumatic arthritis, the neuropathic joint as well as some other conditions. We present a case of a thirty-five-year-old man with a lower leg fracture and significant bone defect associated with the loss of the articular surface of the distal tibia which was treated with a retrograde calcaneo-talo-tibial nail. Due to the lack of an adequate implant on the market, an inversely introduced tibial nail was used. Following the nailing of the fracture and the recovery of the soft tissue, transposition of the ipsilateral fibula was performed. Nowadays, different methods for bone defect reconstruction are available such as distraction osteogenesis, bone transport, and the Masquelet technique. However, the calcaneo-talo-tibial nail and transposition of the fibula is another feasible and effective option, especially for unreconstructable joint surfaces.

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Tibial shaft fractures are the most common long bone injury and are often treated surgically in an attempt to minimize complications. Although treatment options for tibial shaft fractures vary based on factors including open injury, severity of fracture, and soft tissue status, intramedullary nailing in adults has emerged as the preferred definitive option for stabilization. Therefore, the primary purposes of this review and cadaveric study were to evaluate the entry points for reamed tibial nails and the risks, benefits, and advantages of each approach. Due to concerns of violating the joint capsule and the generalized applicability to everyday practice of the extra-articular lateral parapatellar semi-extended technique, the secondary goal of this manuscript was to evaluate whether an intramedullary tibial nail can be consistently placed extra-articularly using the lateral parapatellar technique described by Kubiak et al. and generalizability to surgeons of varying experience.

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The goal of this article is to aid the orthopedic surgeon in determining whether an intra-medullary (IM) device for fixation of a distal tibia fracture is feasible. Using Computed Tomography (CT) scans of the fracture, this review demonstrates a simple way to determine whether two or even three distal interlocking screws are achievable in stable bone. Additionally, this paper offers a summary chart of commonly used tibial nails which can be used for planning purposes. Finally, a clinical summary of very distal tibial shaft fractures treated with IM fixation is provided.

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BACKGROUND: Tibial shaft fractures are a relatively common injury and contemporary treatment includes on-axis fixation with a locked intramedullary nail in the majority of cases. The conventional technique is via an infrapatellar approach but currently there is a trend towards the use of a suprapatellar approach. We compared key variables including operative time, radiation exposure and early patient reported outcomes when adopting a suprapatellar approach to tibial nailing in our unit versus our previous experience of infrapatellar tibial nailing. METHOD: Twenty-eight consecutive patients with tibial fracture underwent tibial nailing via the suprapatellar (SPN) approach. Six patients in the study group were excluded due polytrauma and need for dual orthopaedic and plastic surgery management. We compared outcomes with our most recent 20 consecutive patients who had undergone tibial nailing via an infrapatellar (IPN) approach. Primary surgical outcomes were: operative time, radiation exposure and accuracy of entry point of the nail on both anteroposterior and lateral radiographs. Clinical outcomes included time to weightbearing, time to radiographic union and patient-reported outcome score (Lysholm score). RESULTS: Forty-eight consecutive patients underwent intramedullary nail fixation for tibial shaft fractures and 42 were eligible for inclusion in our study (22 SPN vs 20 IPN). There were no significant differences in patient demographics or injury patterns between the two groups. Operative time and radiation exposure were significantly lower in the SPN group when compared to the IPN group (115 min vs 139 min ± 12.5) (36 cGY/cm2 vs 76.33 cGY/cm2 +/- 20.1). Furthermore, patients in the SPN group reported superior outcome scores at a mean follow up of 3 months (8-24 weeks) There were no observed differences in complication rate between groups and time of final clinical follow up at a minimum of 6 months. CONCLUSION: Our study shows that adoption of the SPN approach requires minimal learning curve, and has the potential benefits of reduced operative time, radiation exposure and superior patient reported outcomes when compared to the conventional infrapatellar approach.

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Introduction Nonunion after fixation of long bones negatively impacts outcomes and requires additional surgery. The ability to predict likelihood of nonunion after tibial shaft fracture would be helpful to clinicians and patients. The goal of this work was to combine three previous models of tibial shaft nonunion at different time points into one overall model that incorporates time as a continuous variable. Methods We conducted a retrospective review at a Level I academic trauma center. The study cohort consisted of patients with tibial shaft fractures treated with nail insertion from 2007 through 2014, excluding patients who did not have contact between bone ends, those who had planned bone grafting for acute bone defects, and those who lacked adequate follow-up. Three previous models were combined: 382 patients at time 0, 323 at 6 weeks, and 240 at 12 weeks. The primary outcome variable was surgery for nonunion. Bivariate and multivariate regression analyses determined which of 42 clinical and radiographic variables were significantly associated with nonunion. Predictive power was evaluated using area under the curve (AUC). Results The original nonunion risk determination (NURD) score was significantly improved through addition of 6- and 12-week radiographic union scores for tibial fractures, infection and complications, smoking status, and need for flaps. Overall, over the course of 12 weeks, the NURD-based model produced an AUC of 0.87 at initial time of fixation that improved to >0.9 at 6 and 12 weeks. Data were used to bin patients into five clinically important risk strata (p < 0.001). Patients in the lowest risk strata had 0% probability of nonunion (0 of 97 patients); in the second lowest risk strata, 4% (three of 73 patients); and in the highest risk strata, 48% (38 of 80 patients). Conclusions We created a NURD 2.0 score that predicts nonunion at various time points during the first 3 months after fracture. The new model is a notable improvement over previous models. A computerized version allows surgeons and patients to use the score when making treatment decisions regarding need for nonunion surgery.

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INTRODUCTION/PURPOSE: Total knee arthroplasty (TKA) in the setting of previous periarticular hardware increases resource utilization, readmissions, complications, and revision rates. Despite the frequency of intramedullary nail (IMN) fixation for tibial fractures, little guidance exists on the management of these patients and no series have reported on outcomes of patients undergoing TKA in the setting of a retained or removed IMN. METHODS: This is a retrospective case series of patients who underwent TKA after IMN fixation of tibial fractures. Patient and case data, including need for hardware removal, staged vs non-staged procedures, operative time, and need for revision implants, were recorded. Postoperative data, including complications and revision, were recorded. Oxford Knee Score (OKS) was performed at follow-up. RESULTS: Nine patients were identified consisting of eight women and one man. Follow-up ranged from 0.8-13 years. Non-staged removal of the intramedullary hardware occurred in three cases that had increased operative lengths recorded. There were no complications related to wound healing or infection. No patients required revision. Two of the three patients who underwent non-staged TKA developed arthrofibrosis requiring manipulation. OKS scores in patients who underwent non-staged surgery were consistently low. CONCLUSIONS: Conversion TKA after tibial IMN fixation can result in satisfying outcomes in many patients. However, intramedullary hardware presents challenges to TKA similar to more extensively studied conversion TKA scenarios. Removing hardware in either a staged or non-staged fashion results in increased resource utilization and imparts perioperative challenges with only theoretical benefits of one approach compared to the other. Increased stiffness may be associated with a non-staged approach to hardware removal and TKA. Several technical factors may permit component positioning without removal of hardware. Despite limitations, this is the first series to discuss this challenging clinical scenario and provides surgeons with technical guidance and data on operative outcomes.

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BACKGROUND: As the use of intramedullary nails (IMNs) has become more common, there are an increasing number of patients requiring total knee arthroplasty (TKA) who have an indwelling tibial IMN. The purpose of this study is to compare implant survivorship, clinical outcomes, and complications in patients undergoing primary TKA with a history of tibial IMN to those without. METHODS: We retrospectively identified 24 TKAs performed between 2000 and 2017 after ipsilateral tibial IMN. Patients were matched 1:2 to patients undergoing primary TKA without history of tibial IMN based upon age, gender, body mass index, and year of surgery. Mean follow-up was 7 years. RESULTS: The 10-year survivorship free of any revision was 100% for the tibial IMN cohort, and 96% for the control cohort, while the 10-year survivorship free of any reoperation was 91% and 89%, respectively (P = .72). Patients with a history of tibial IMN had similar Knee Society Scores to matched controls at 2 years (P = .77) and 5 years (P = .09). Acquired idiopathic stiffness trended toward being more common (17% vs 6%, P = .21) and operative time trended toward being longer (135 vs 118 min, P = .07) when the tibial IMN was removed, but there was no overall difference in complication rate between cohorts. CONCLUSIONS: To our knowledge, this is the first report of primary TKA in patients with a history of ipsilateral tibial IMN. Compared to a matched cohort of patients without tibial IMN, these patients have similar outcomes in regards to implant survivorship, clinical outcomes, and risk of complications. LEVEL OF EVIDENCE: Therapeutic Level III.

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PURPOSE: We present the Aberdeen Weight-Bearing Test (Knee), an objective test specific for anterior knee discomfort assessed via load bearing. We assess its validity by performing it on normal subjects with no knee symptoms and subjects who had undergone anterograde tibial nailing. METHODS: Two scales are placed parallel on the floor with the dials concealed from the subject. The subject then kneels with one knee on each scale. The weight through each knee is recorded at 0, 15, 30, 45, and 60 s. The proportion of total body weight on each leg at each timepoint is calculated, and a ratio calculated from the values. A value of 1 equates to equal weight on each leg. The test was performed on 53 normal subjects and 38 subjects who had undergone tibial nailing. RESULTS: In the normal group, no significant difference in mean ratio of weight distribution (left:right) was seen at any timepoint (mean ratio range = 0.98-0.99, p value range = 0.18-0.64). In the tibial nail group, a difference was observed in mean ratio of weight distribution (injured:uninjured) favouring the uninjured leg, reaching significance at 0, 15, 30, and 45 s (mean ratio range = 0.88-0.94, p value range = 0.01-0.02). At 60 s, the mean ratio was 0.93 (p = 0.09). CONCLUSION: The Aberdeen Weight-Bearing Test (Knee) is an objective, easily reproducible, specific test for anterior knee discomfort. It produces different results in individuals who have undergone anterograde tibial nailing compared to individuals with no knee symptoms.

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PURPOSE: During fracture fixation, the size of tibial nail is a vital factor affecting the outcomes and thus preoperative estimation of tibial nail length is very important. This study aims to find out whether "olecranon to 5th metacarpal head" (O-MH) measurement can be used to reliably predict the tibial nail length. METHODS: This was a cross sectional study involving 100 volunteers. Measurements were done and recorded by two observers on two separate occasions. Tibial nail length estimation measurement was done from highest point of tibial tuberosity to the tip of the medial malleolus (TT-MM). O-MH measurement was taken from tip of olecranon to the tip of 5th metacarpal head with wrist in neutral position and hand clenched. Statistical analysis was done to find out correlation between two measurements and influence of age, gender and body mass index on them. RESULTS: Paired t-test showed no systematic error between the readings. Intraclass correlation coefficient showed strong agreement in inter and intra observer settings. Strong correlation was found between the TT-MM & O-MH measurements using Pearson's correlation coefficient test (r = 0.966). Hierarchical regression analysis showed age, gender and BMI have no statistically significant bearings on these measurements and their correlations. CONCLUSION: O-MH measurement is a useful and accurate means of estimating tibial nail length preoperatively.

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BACKGROUND: Treatment of tibial diaphyseal nonunions are rather difficult. Plate-screw, intramedullary nailing and external fixation are the methods used for treatment. The aim of this study is to evaluate the treatment results of aseptic diaphyseal nonunions following tibia fractures by intramedullary compressive tibia nailing (IMCN) with or without bone graft. MATERIALS AND METHODS: Twenty eight patients who had aseptic tibial nonunion without bone defects operated between 2005 and 2015 were included in the study. The mean age of our patients was 36.4 years (range 20-56 years). There were 22 males and 6 females. Fifteen of the patients exhibited hypertrophic nonunion and thirteen exhibited atrophic nonunion. The average time between fracture occurrence and presentation to our department was 1.6 years (range 1-20 years). All patients underwent fibular osteotomy by removal of a 2 cm bone block from the middle one-third of the fibulas. In all cases, IMCN was applied following the reaming procedure, then maximum bone contacts were achieved manually between proximal and distal bone fragments afterward, and dynamic compressive fixation with 1 mm of compression was performed by a single rotation of the compression screw at the top of the nail. Direct X-ray images were assessed according to the Rust criteria, and functional outcomes were assessed according to the Johner-Wrush criteria. Finite-element analysis was performed for 1 mm of compression. For statistical analysis, Fisher's exact test, Pearson's Chi-square test, and Mann-Whitney U-test were used. RESULTS: Union was achieved in all patients. Radiological union was obtained at an average of 15.5 ± 1.86 weeks. Functional results were found to be good or excellent in 25 (89.2%) patients and average or poor in 3 (10.8%) patients. One patient developed skin necrosis at the wound site, which was treated with rotational flap and skin graft. None of the patients developed implant failure, thromboembolism, deep-vein thrombosis, or infection. CONCLUSIONS: The use of compressive intramedullary nailing with or without bone graft is an effective method for the treatment of tibial nonunion.

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Purpose:@#During fracture fixation, the size of tibial nail is a vital factor affecting the outcomes and thus preoperative estimation of tibial nail length is very important. This study aims to find out whether "olecranon to 5th metacarpal head" (O-MH) measurement can be used to reliably predict the tibial nail length. @*Methods:@#This was a cross sectional study involving 100 volunteers. Measurements were done and recorded by two observers on two separate occasions. Tibial nail length estimation measurement was done from highest point of tibial tuberosity to the tip of the medial malleolus (TT-MM). O-MH measurement was taken from tip of olecranon to the tip of 5th metacarpal head with wrist in neutral position and hand clenched. Statistical analysis was done to find out correlation between two measurements and influence of age, gender and body mass index on them. @*Results:@#Paired t-test showed no systematic error between the readings. Intraclass correlation coefficient showed strong agreement in inter and intra observer settings. Strong correlation was found between the TT-MM & O-MH measurements using Pearson's correlation coefficient test (r = 0.966). Hierarchical regression analysis showed age, gender and BMI have no statistically significant bearings on these measurements and their correlations. @*Conclusion:@#O-MH measurement is a useful and accurate means of estimating tibial nail length preoperatively.

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INTRODUCTION: The purpose of this study was to determine the radiographic parameters associated with symptomatic locking screw removal after intramedullary tibial nail insertion. Our hypothesis was that locking screws located closer to joints and those extending longer than the width of the bone result in more symptomatic implant removal. METHODS: We conducted a retrospective cohort study at our Level I trauma center. Seventy-five patients underwent surgical removal of symptomatic locking screws from 2007 to 2014 and were compared with a control group of 122 patients from the same time period who did not undergo symptomatic locking screw removal. Our main outcome measures were radiographic and demographic factors associated with implant removal. RESULTS: Multivariable regression indicated that a proximal locking screw that started anterolateral and was directed posteromedial was the strongest radiographic predictor of symptomatic removal (odds ratio [OR], 2.83; p = 0.03). An Injury Severity Score <11 (OR, 3.10; p < 0.001) and a body mass index <25 kg/m2 (OR, 2.15; p = 0.02) were also associated with locking screw removal. The final prediction model discriminated patients requiring symptomatic locking screw removal with moderate accuracy (area under the receiver operating characteristic curve = 0.73). CONCLUSIONS: The strongest radiographic predictor for symptomatic locking screw removal after tibial nail insertion was the direction of the most proximal locking screw. In contrast to previous research on retrograde femoral nails, tibial locking screws that were closer to the joints were not associated with an increased likelihood of symptomatic screw removal. Clinicians can use these data to help counsel patients regarding the likelihood of symptomatic screws and perhaps to help guide screw placement in cases with multiple options.

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