What are the key points for proximal metaphyseal fracture of the tibia treated with interlocking intramedullary (IM) nailing?

From the Guidelines

Intramedullary nailing of proximal metaphyseal tibial fractures requires careful consideration of technical factors to achieve optimal outcomes, including the use of a suprapatellar or semi-extended approach, precise starting point placement, and multiple blocking or poller screws to prevent malalignment. The key points for successful interlocking nailing of these fractures include:

• Using a suprapatellar or semi-extended approach to prevent apex anterior deformity, as this position neutralizes the deforming forces of the patellar tendon 1
• Placing the starting point more proximal and lateral than in standard nailing, typically at the anterior edge of the tibial plateau just medial to the lateral tibial spine
• Utilizing multiple blocking or poller screws to guide the nail and prevent malalignment, particularly to counteract valgus and anterior displacement of the proximal fragment
• Positioning the nail eccentrically in the proximal fragment, and considering the use of a shorter, thicker nail with multiple proximal locking options
• Ensuring stable fixation with at least three proximal interlocking screws in different planes, with particular attention to obtaining oblique and anteroposterior screws
• Considering fibular fixation to provide additional stability in some cases
• Approaching early weight-bearing cautiously, with protected weight-bearing initially recommended until callus formation is evident, as supported by the principles outlined in the management of proximal femoral fractures 1.

These techniques address the challenges of proximal metaphyseal tibial fractures, including the mismatch between the medullary canal and nail dimensions in the metaphyseal region and the deforming muscular forces that can lead to malalignment if not properly managed. By following these guidelines, surgeons can optimize outcomes and minimize complications in the treatment of these complex fractures.

From the Research

Key Points of Proximal Metaphyseal Fracture of Tibia Interlocking Nailing

• The treatment of proximal metaphyseal fractures of the tibia is challenging, and the optimal surgical strategy remains a matter of debate 2.
• Intramedullary nailing (IMN) is a common treatment option for these fractures, and it has been shown to lead to a shorter time-to-union and shorter operation duration compared to plate fixation 2.
• However, IMN is associated with a higher risk of mal-union and anterior knee pain, while plate fixation results in an increased risk of infection 2.
• Semi-extended nailing of metaphyseal tibia fractures has been shown to result in similar knee pain and alignment compared to standard nailing in hyperflexion 3.
• The choice of treatment should be based on patient-specific needs and fracture characteristics, and a personalized approach is recommended 2, 4, 5.

Comparison of Treatment Options

• IMN and minimally invasive plate osteosynthesis (MIPO) have been compared in several studies, with similar clinical results and marginally enhanced functional outcomes seen with IMN 4, 5.
• However, IMN requires more frequent secondary surgeries for the removal of painful distal locking screws 4.
• The role of fibula fixation in distal tibia fractures is still debated, but it may improve rotational alignment in certain fracture patterns 5.

Complications and Outcomes

• The complications of IMN and MIPO include non-union, mal-union, infection, and wound complications 2, 4, 6, 5.
• The outcome of distal tibia fractures treated with IMN or MIPO is generally good, with most patients achieving union and functional recovery 2, 4, 5.
• However, the treatment of these fractures is challenging, and a high incidence of complications can occur, especially in complex fracture patterns 6.