Reduction techniques for intramedullary nailing of tibial shaft fractures: a comparative study

Abstract

Objectives: To assess the impact of various reduction techniques on postoperative alignment following intramedullary nail (IMN) fixation of tibial shaft fractures.

Design: Retrospective comparative study.

Setting: Level I trauma center.

Patients: Four hundred twenty-eight adult patients who underwent IMN fixation of a tibial shaft fracture between 2008 and 2017.

Intervention: IMN fixation with use of one or more of the following reduction techniques: manual reduction, traveling traction, percutaneous clamps, provisional plating, or blocking screws.

Main outcome measures: Immediate postoperative coronal and sagittal plane alignment, measured as deviation from anatomic axis (DFAA); coronal and sagittal plane malalignment (defined as DFAA >5° in either plane).

Results: Four hundred twenty-eight patients met inclusion criteria. Manual reduction (MR) alone was used in 11% of fractures, and adjunctive reduction aids were used for the remaining 89%. After controlling for age, BMI, and fracture location, the use of traveling traction (TT) with or without percutaneous clamping (PC) resulted in significantly improved coronal plane alignment compared to MR alone (TT: 3.4°, TT+PC: 3.2°, MR: 4.5°, P = .007 and P = .01, respectively). Using TT+PC resulted in the lowest rate of coronal plane malalignment (13% vs 39% with MR alone, P = .01), and using any adjunctive reduction technique resulted in decreased malalignment rates compared to MR (24% vs 39%, P = .02). No difference was observed in sagittal plane alignment between reduction techniques. Intraclass correlation coefficient (ICC) results indicated excellent intraobserver reliability on both planes (both ICC>0.85), good inter-observer reliability in the coronal plane (ICC = 0.7), and poor inter-observer reliability in the sagittal plane (ICC = 0.05).

Conclusions: The use of adjunctive reduction techniques during IMN fixation of tibia fractures is associated with a lower incidence of coronal plane malalignment when compared to manual reduction alone.

Level of evidence: Therapeutic Level III.

Keywords: alignment; blocking screw; intramedullary nail; manual reduction; percutaneous clamp; reduction technique; tibia fracture; traveling traction.

Figure 1

(A–G) Adjunctive reduction techniques used to achieve satisfactory reduction during intramedullary nailing. (A) Fluoroscopic view demonstrating a percutaneous clamp used to achieve reduction prior to nail passage. (B) AP and lateral radiographs of a segmental tibia fracture. (C) Clinical photo demonstrating traveling traction along with 2 percutaneous clamps. (D) AP and lateral fluoroscopic images of the same patient demonstrating 2 percutaneous clamps used in conjunction with traveling traction. (E) Lateral fluoroscopic views of a provisional plate applied temporarily. (F) Lateral fluoroscopic views of a provisional plate to maintain reduction during nail passage. (G) Lateral fluoroscopic view demonstrating placement of a posterior blocking screw (arrow) in the proximal segment to maintain satisfactory sagittal plane alignment.