|Year : 2022 | Volume
| Issue : 1 | Page : 56-59
The clinical and radiological assessment of biplanar and uniplanar distal locking screw in tibia interlocking nail
Ashutosh Kumar1, Rishabh Kumar1, Anand Shanker1, Rakesh Kumar1, Vidya Sagar2, Santosh Kumar2
1 Department of Trauma and Emergency, IGIMS, Patna, Bihar, India
2 Department of Orthopaedics, IGIMS, Patna, Bihar, India
|Date of Submission||30-Jan-2022|
|Date of Acceptance||03-Feb-2022|
|Date of Web Publication||12-Feb-2022|
Department of Orthopaedics, IGIMS, Patna, Bihar
Source of Support: None, Conflict of Interest: None
Background: The clinical and radiological assessment of biplanar (two coronal and one sagittal) and uniplanar (only two coronal) distal locking screw in tibia interlocking nailing.
Materials and Methods: Fifty-one patients who had tibial shaft treated with intramedullary nailing were included in this study. Out of 51, 26 fractures were treated with uniplanar two distal interlocking (Group 1) and 25 fractures were treated with biplanar three distal interlocking (Group 2). Patients with closed fractures shaft of tibia treated by closed nailing were included. Fracture unions were evaluated clinically and radiologically.
Results: Union time was shorter in biplanar (two coronal and one sagittal) distal interlocking group (Group 2) compared to uniplanar (only two coronal) distal interlocking group (Group 1). Mean union time in Groups 1 and 2 were 9.34 and 5.16 months, respectively.
Conclusion: Biplanar (two coronal and one sagittal) distal interlocking procedure had a significantly shorter union time. Clinically, an average of 5–10' of external rotation of the leg was observed in Group 1, whereas 0–3' of external rotation of the leg was observed in Group 2 patients. Biplanar distal interlocking had more fracture union, probably because of a more stable fixation.
Keywords: Biplanar, distal interlocking screw, intramedullary nailing, tibia shaft fracture, union time, uniplanar
|How to cite this article:|
Kumar A, Kumar R, Shanker A, Kumar R, Sagar V, Kumar S. The clinical and radiological assessment of biplanar and uniplanar distal locking screw in tibia interlocking nail. J Indira Gandhi Inst Med Sci 2022;8:56-9
|How to cite this URL:|
Kumar A, Kumar R, Shanker A, Kumar R, Sagar V, Kumar S. The clinical and radiological assessment of biplanar and uniplanar distal locking screw in tibia interlocking nail. J Indira Gandhi Inst Med Sci [serial online] 2022 [cited 2022 Oct 2];8:56-9. Available from: http://www.jigims.co.in/text.asp?2022/8/1/56/338358
| Introduction|| |
Intramedullary nailing is the standard treatment for tibial shaft fractures. A good internal fixation is necessary for fracture healing after surgical treatment of these fractures. However, whenever there is distal third tibia fracture, the stability provided by any nail decreases precipitously. Nailing was ideally recommended for tibia diaphyseal fractures that are more than 5 cm above the ankle joint. However, the new types of interlocking nails allow more distal interlocking screws in distal third fractures treatment with intramedullary nailing and have good results. However, we know that one distal locking screw is not sufficient for rigid and stable fixation. The ideal number and plane of distal interlocking screws remain controversial.,,, The medial to lateral interlocking with two screws is the most commonly used due to the ease of application. Two distal interlocking screws were reported superior to one screw, mainly for the distal third fractures. However, we analyzed that biplanar interlocking with three interlocking screws provides no or less external rotation of the leg and thus more rigid and stable fixation that fastens the fracture healing time of tibia shaft fractures. The aim of the study was to assess the clinical status of the leg (neutral/external rotation) and compare the union rate of the tibial shaft fractures, which were locked by two coronal plane screws and one sagittal plane screws and by only two coronal plane screws.
| Materials and Methods|| |
A retrospective study was done in the Department of Orthopaedic at Indira Gandhi Institute of Medical Sciences, Patna, between January 2017 and February 2019. This study includes Muller AO Type A or B (simple and complex) fracture, who has isolated closed low-energy tibia shaft fractures. All operations were done in the same unit. The close reduction of fracture site followed by reaming and fixation of fracture done by interlocking nail. The following patients were excluded from the study. The fractures with gap of over 5 mm postoperatively, patients who did not follow-up until the bone healing was completed and patients who had complications like delay/nonunion due to infection or implant failure were not included in this study.
Totally 51 patients (22 female, 29 male) were included in this study and evaluated for their fracture type, fracture localization, uni or biplanar distal interlocking screw configurations, and fracture union time along with their age and sex. Fractures involving lower or distal third of the tibial shaft were considered as “distal third fractures” in the study. All interlocking nails were locked by two proximal locking screws. While 26 of 51 fractures were treated with uniplanar two distal interlocking (Group 1) [Figure 1] and 25 fractures were treated with biplanar three distal interlocking (Group 2) [Figure 2]. Distal interlocking was applied by freehand techniques. Details of the patients are shown in [Table 1].
|Figure 1: Shaft of tibia fracture with uniplanar screw (two coronal screws). (a) Before surgery, (b) six months after surgery, and (c) nine months after surgery|
Click here to view
|Figure 2: Shaft of tibia fracture with biplanar screw (two coronal and one sagittal screws). (a) Before surgery, (b) six months after surgery, and (c) nine months after surgery|
Click here to view
|Table 1: Degree of external rotation of leg and time period of union of fracture after uniplanar and biplanar tibia distal locking screws|
Click here to view
Clinical assessment and radiographs images were taken at sequential follow-up at 0-, 1-, 3-, 6-, and 12-month intervals. Two groups were compared clinically by external rotation of the leg and radiologically by fracture union. Clinical assessment for external rotation of the leg measured by line drawn from center of patella to tibial tuberosity and center of the ankle joint to second toe. Normally, if a line is drawn from center of patella to second toe, it passes through tibial tuberosity and center of the ankle joint. It is compared with the normal leg [Figure 3].
|Figure 3: A line drawn from the center of the patella to the second toe, it passes through the tibial tuberosity and center of the ankle joint. It is compared with normal leg|
Click here to view
The union of fracture site was said to be complete when there was bridging callus between the main fragments and at least three cortices on both X-ray views anteroposterior and lateral.
Preoperatively, antibiotics were given before surgery for all patients. No tourniquet was used in all the cases. Active physiotherapy and partial weight-bearing with crutches were started after the 1st postoperative day to all patients.
| Results|| |
Mean ages were 42.6 and 43.1 in Groups 1 and 2, respectively. According to the AO Muller fracture classification, 14 of 26 (53%) patients in Group 1 and 12 of 25 (48%) patients in Group 2 had Type A fractures and the rest were Type B fractures. There was no difference between the groups with regard to fracture Types. 11 of 26 patients in Group 1 and 11 of 25 patients in Group 2 were female. No difference about sex distribution was observed between groups.
All patients had tibial shaft fractures, 12 of 26 patients in Group 1 and 13 of 25 patients in Group 2 had distal third tibial shaft fractures.
Union time was significantly shorter in biplanar distal interlocking group (Group 2) compared to uniplanar distal interlocking group (Group 1). Mean union time in Group 1 was 9.34 months and in Group 2 was 5.15 [Table 1].
| Discussion|| |
Thus, this study shows that the faster rate of fractures healing which had distally locked in two planes and by three screws. The distal locking with two screws done in the same plane, and another locking screw done perpendicular to the axis, resist any type of movement more strongly than one sagittal and one coronal plane or two coronal plane screws. The results of this study contradict to Ramos et al. For a better stability, reaming of canal and thus larger nail can be applied. Fractures in the distal part of the tibial shaft are likely to go in delayed or nonunion compared with shaft fractures. The distal third tibia fractures are likely to go in slow healing or nonunion, compared to mid shaft fractures after intramedullary nailing.,,,, This is due to large medullary canal, it decreases the stability of the intramedullary nailing and fixation. Hence, increased stability of the construct by biplanar distal locking with one sagittal screw and two coronals. Thus, routine use of three interlocking screws in biplanar mode for intramedullary nailing of distal third tibial fractures are more stable for fracture union and prevent external rotation of the leg.
However, the limitation of the study is the small sample size. Better results may be obtained if more patients were added. Furthermore, the true healing time of any fracture may be interobserver variability.,,
| Conclusion|| |
Thus, we concluded from this study that biplanar distal interlocking had a significantly shorter union time and also prevent external rotation of the leg. Biplanar distal interlocking produces faster fracture union because of a more stable fixation construct.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Alemdaroğlu KB, İltar S, Ozturk A, Gültaç E, Yücens M, Aydoğan NH. The role of biplanar distal locking in intramedullary nailing of tibial shaft fractures. Arch Bone Jt Surg 2019;7:33-7.
Beardi J, Hessmann M, Hansen M, Rommens PM. Operative treatment of tibial shaft fractures: A comparison of different methods of primary stabilisation. Arch Orthop Trauma Surg 2008;128:709-15.
Wood GW. General principles of fracture treatment. In: Terry MS, editor. Campbell's Operative Orthopaedics. 11th
ed. Mosby Elsevier; 2011. p. 3057.
Alho A, Ekeland A, Strømsøe K, Follerås G, Thoresen BO. Locked intramedullary nailing for displaced tibial shaft fractures. J Bone Joint Surg Br 1990;72:805-9.
Russel T. Fractures of the tibia and fibula. In: Green DP, editor. Rockwood and Green's Fractures in Adults. 4th
ed. Philadelphia: Lippincott Williams & Wilkins; 1996. p. 2157.
Nork SE, Schwartz AK, Agel J, Holt SK, Schrick JL, Winquist RA. Intramedullary nailing of distal metaphyseal tibial fractures. J Bone Joint Surg Am 2005;87:1213-21.
Kneifel T, Buckley R. A comparison of one versus two distal locking screws in tibial fractures treated with undreamed tibial nails: A prospective randomized clinical trial. Injury 1996;27:271-3.
Mohammed A, Saravanan R, Zammit J, King R. Intramedullary tibial nailing in distal third tibial fractures: Distal locking screws and fracture non-union. Int Orthop 2008;32:547-9.
Fan CY, Chiang CC, Chuang TY, Chiu FY, Chen TH. Interlocking nails for displaced metaphyseal fractures of the distal tibia. Injury 2005;36:669-74.
Ramos L, Bertrand ML, Benitez-Parejo N, Guerado E. How many distal bolts should be used in unreamed intramedullary nailing for diaphyseal tibial fractures? Injury 2012;43 Suppl 2:S59-62.
Audigé L, Griffin D, Bhandari M, Kellam J, Rüedi TP. Path analysis of factors for delayed healing and nonunion in 416 operatively treated tibial shaft fractures. Clin Orthop Relat Res 2005;438:221-32.
Bilat C, Leutenegger A, Rüedi T. Osteosynthesis of 245 tibial shaft fractures: Early and late complications. Injury 1994;25:349-58.
Funsten RV, Lee RW. Healing time in fractures of the shafts of the tibia and femur. J Bone Joint Surg 1945;27:395-400.
Heppenstall RB, Brighton CT, Esterhai JL Jr., Muller G. Prognostic factors in nonunion of the tibia: An evaluation of 185 cases treated with constant direct current. J Trauma 1984;24:790-5.
Thelen S, Betsch M, Grassmann JP, Spoor V, Eichler C, Koebke J, et al.
Angle stable locking nails versus conventionally locked intramedullary nails in proximal tibial shaft fractures: A biomechanical study. Arch Orthop Trauma Surg 2012;132:57-63.
Wähnert D, Stolarczyk Y, Hoffmeier KL, Raschke MJ, Hofmann GO, Mückley T. Long-term stability of angle-stable versus conventional locked intramedullary nails in distal tibia fractures. BMC Musculoskelet Disord 2013;14:66.
[Figure 1], [Figure 2], [Figure 3]