Radiation-free Insertion of Interlocked Intramedullary Tibial Nail in Closed Extra-articular Displaced Tibial Shaft Fractures in an Emergency Setup

Background. Interlocking nailing is considered a gold standard surgical treatment of mid-shaft closed diaphyseal tibial fractures. With increasing exposure of orthopaedic surgeons to radiation, we propose a solution to this health hazard through a study wherein we perform the surgery without any radiation or C-arm exposure. Material and methods. This prospective study was done at GMC Jammu from January 2017 to February 2020 and included 218 patients, with 18 patients having bilateral tibia fractures in the age group 15 to 58 years (mean of 37.6 years), including 63.7% males (n=139) and 36.3% females (n=79). The 236 extra-articular closed tibial mid-diaphyseal fractures were operated on and intramedullary tibial nailing was performed without a single C-arm exposure. Postoperative x-rays were done and reduction assessed by standard acceptable criteria. Results. Among 236 cases in which nailing was done, 227 (96%) patients were successfully distally locked, including 128 (56.3%) locked through the jig and 99 (43.6%) by “hit and trial method.” All cases met acceptability criteria set for management of tibia by nailing. Conclusions. 1.This study strengthens the proof that closed extra-articular diaphyseal fractures of the tibia can be managed by nailing without using the C-arm with excellent results. 2.The C-arm is always available for cases where distal locking could not be achieved. 3. The technique has a great role in centres with limited facilities of intra-operative radiography in emergency operation theatres.

Functional outcome of proximal 1/3rd, distal 1/3rd and diaphysial tibial fractures in adults operated with expert tibial nailing

<p class="abstract"><strong>Background:</strong> Fractures of the tibial shaft are increasing due to high velocity trauma and industrialisation. Not only they are common but also difficult to treat. Until recently surgeons had to rely on non-operative treatment, V nailing, plates and screws and external fixator but they had their drawbacks like prolonged immobilisation infection, delayed union and non-union. Numerous modifications in nail and screw design have led to development of the expert tibial nail. Multidirectional interlocking screws ensure that alignment can be well maintained and stability preserved in short proximal or distal tibial segments.</p><p class="abstract"><strong>Methods:</strong> 30 patients were admitted and operated during September 2014 to September 2016 in Mamata general hospital Khammam. All patients were evaluated with Klemm Borner’s criteria and complications following surgery.<strong></strong></p><p class="abstract"><strong>Results:</strong> 87% of patients achieved good or excellent results, fair results were obtained in 3 (10%) patient and poor result in one (3%) patient. 2 (6%) patients had malunion, 2 (6%) patients had delayed union, 1 (3%) patient had deep infection led to implant failure.</p><p class="abstract"><strong>Conclusions:</strong> Intramedullary nailing is a safe and effective technique for the treatment of tibial metaphyseal fractures. It avoids the additional soft-tissue dissection associated with traditional open procedures as well as the complications associated with external fixators. Expert tibial nail can give excellent functional and clinical results. Complications such as failure of the bone-implant construct or post-operative malallignment are avoidable if careful pre-operative planning is allied with meticulous surgical technique.</p>

Preoperative Determination of Tibia Length Using Contralateral Tibial Tubercle-Medial Malleolar Distance (TMD) in Western Part of Nepal

INTRODUCTION Intramedullary (IM) nailing is most commonly preferred for adult tibial shaft fracture. The objective of this study was to find the accuracy of predicting the tibial nail length pre-operatively from contra-lateral tibial tubeorsity to medial malleolar distance (TMD) length. MATERIAL AND METHODS After ethical clearance (UCMS/IRC/239/19) from the Institutional Review Board (IRB) of Universal College of Medical Sciences, all patients with recent fracture of tibia, who fulfilled the inclusion criteria were enrolled in the study and the informed written consent was obtained. The study was conducted on 45 patients of aged more than 15 years who attended Universal College of Medical Sciences Teaching Hospital (UCMS-TH) over a period of one year (Nov 2019 to Oct 2020). The TMD length of contra-lateral leg were measured preoperatively using a measuring tape and the ideal length of IM nail were measured intra-operatively using IM tibial nail under fluoroscopic guidance. RESULTS Analysis showed that majority of patients were males (77.78%) out of total 45 patients. The mean length of TMD length of contra-lateral leg and the ideal length of IM nail were 33.067 ±1.60 and 33.11 ±1.68 respectively. The mean difference between these two measurements was 0.04 (95% CI, -0.64 to 0.72). The significant correlation was found between these two measurements i.e r=0.88 by Pearson’s correlation (95% CI, 0.79 to 0.93), (p<0.001). Most of the TMD length were equal (37.78%) to ideal length of IM nail. CONCLUSION We recommended TMD length measurement of contralateral leg as an excellent anthropometric parameter for preoperative planning.

Formulae derived from Anthropometric Measurements to Estimate Ideal Tibial Nail Length

ABSTRACT Introduction: Ideal Nail Length (INL) provides better outcomes after Intramedullary Nailing (IMN) of Tibia Shaft Fractures (TSF). Intraoperative methods do not allow for preoperative planning. Changing the nail may cause complications. X-rays are commonly used, but displacement or magnification errors may occur. Forearm measurements may be benefical in bilateral TSF. We aim to examine correlations of anthropometric measurements (AMs) and INL and use them to obtain formulae. Materials and methods: Tuberositas Tibia-Medial Malleolus (TM), Tuberositas Tibia-Ankle joint (TA), knee-ankle joint (JJ), and olecranon tip-5th Metacarpal head (OM) distances were evaluated in 76 IMN patients. Correlation analyses were performed and the results used to create formulae. Results: The correlations between INL and TM-left, TM-right, TA-left, TA-right, OM-left, OM-right, JJ-left, JJ-right were 0.81, 0.83, 0.77, 0.77, 0.82, 0.80, 0.90, 0.91 respectively for males; and 0.93, 0.89, 0.88, 0.86, 0.80, 0.82, 0.90, 0.89 respectively for females. AMs show excellent correlation in both sexes (p<0.0001). Regression analysis was statistically significant in all formulae. The most compatible correlations in males were JJ-right and JJ-left; and in females, TM-left, TM-right, and JJ-right. Conclusion: The most compatible correlations wth INL were JJ in males, and TM and JJ in females. OM can be used in the presence of bilateral TSF, edema, wounds and obesity. AMs are useful preoperatively. The formulae can be used to ensure INL and reduce errors, time and radiation. Level of Evidence: Level I, Testing of previously developed diagnostic criteria on consecutive patients (with the universally applied reference gold standard).

Visualization of Fluoroscopic Imaging in Orthopedic Surgery: Head-Mounted Display vs Conventional Monitor

Purpose. See-through head-mounted displays (HMDs) can be used to view fluoroscopic imaging during orthopedic surgical procedures. The goals of this study were to determine whether HMDs reduce procedure time, number of fluoroscopic images required, or number of head turns by the surgeon compared with standard monitors. Methods. Sixteen orthopedic surgery residents each performed fluoroscopy-guided drilling of 8 holes for placement of tibial nail distal interlocking screws in an anatomical model, with 4 holes drilled while using HMD and 4 holes drilled while using a standard monitor. Procedure time, number of fluoroscopic images needed, and number of head turns by the resident during the procedure were compared between the 2 modalities. Statistical significance was set at P < .05. Results. Mean (SD) procedure time did not differ significantly between attempts using the standard monitor (55 [37] seconds) vs the HMD (56 [31] seconds) ( P = .73). Neither did mean number of fluoroscopic images differ significantly between attempts using the standard monitor vs the HMD (9 [5] images for each) ( P = .84). Residents turned their heads significantly more times when using the standard monitor (9 [5] times) vs the HMD (1 [2] times) ( P < .001). Conclusions. Head-mounted displays lessened the need for residents to turn their heads away from the surgical field while drilling holes for tibial nail distal interlocking screws in an anatomical model; however, there was no difference in terms of procedure time or number of fluoroscopic images needed using the HMD compared with the standard monitor.