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Terminal position of a tibial intramedullary nail: a computed tomography (CT) based study

European Journal of Trauma and Emergency Surgery volume 46, pages 1077–1083 (2020)Cite this article

Abstract

Purpose

The purpose of this study is to characterize the distal anatomic end-point of a tibial intramedullary nail placed using modern surgical techniques. The goal is to improve reduction of distal tibia fractures.

Methods

An intramedullary nail was placed in 14 skeletally mature legs. This included 8 patients with mid-shaft tibial fractures and 6 intact cadaveric legs. Each nail was a titanium cannulated tibial nail, size 10- or 11-mm. The nails were placed using a suprapatellar or transpatellar approach with an ideal starting point. All legs received post-nail insertion CT scans and fluoroscopy. The main outcome measure was the terminal location of the nail just proximal to the distal tibial physeal scar, as seen on axial CT and fluoroscopic views of the ankle (mortise and lateral). The end-point was measured as the (1) ratio of medial–lateral tibial width (ML ratio) and (2) ratio of anterior–posterior tibial width (AP ratio). Two-tailed Welch’s t tests were used to compare the actual, observed position of the nail to the hypothesized center–center position (H0 = ML and AP ratio of 0.5).

Results

All enrolled patients (n = 8) and cadaveric legs were included (n = 6). On axial CT, the average distance from the medial tibial cortex to the nail center as a ratio of medial–lateral tibial width was 0.63, 95% CI 0.60–0.67, p < 0.001 (Patient = 0.60, 95% CI 0.55–0.64, p = 0.001) (Cadaver = 0.68, 95% CI 0.64–0.73, p < 0.001). On fluoroscopic mortise views, the distance from the medial cortex to the nail center as ratio of medial–lateral tibial width was 0.64, 95% CI 0.60–0.67, p < 0.001 (Patient = 0.61, 95% CI 0.56–0.65, p < 0.001) (Cadaver = 0.67, 95% CI 0.63–0.72, p < 0.001). The AP ratio was not significantly different from 0.5 on either axial CT or fluoroscopic mortise views (p > 0.05).

Conclusion

The distal end-point of a tibial intramedullary nail is lateral (ML plane) and center (AP plane) in both cadaveric legs and patients with midshaft tibia fractures. These results suggest that the treatment of distal tibia fractures with intramedullary nails may be improved by positioning the nail slightly lateral in the distal segment.

Level of evidence

Diagnostic level I.

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Author information

Author notes

  1. Adam P. Schumaier, Frank R. Avilucea contributed equally to this study and are both recognized as first authors.

Affiliations

  1. Department of Orthopaedics and Sports Medicine, University of Cincinnati, Cincinnati, OH, USA

    Adam Phillip Schumaier, Brendan Ryan Southam, Preetha Sinha, Theodore Toan Le, John Dwight Wyrick & Michael Thomas Archdeacon

  2. Orthopaedic Research, Orlando Health Orthopaedic Institute, 1222 S Orange Ave, MP 43, Orlando, FL, 32806, USA

    Frank Roman Avilucea

Authors
  1. Adam Phillip Schumaier
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  2. Frank Roman Avilucea
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  4. Preetha Sinha
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  5. Theodore Toan Le
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Corresponding author

Correspondence to Frank Roman Avilucea.

Ethics declarations

Conflict of interest

The authors have the following disclosures to make: Dr. Brendan Southam receives research support from DePuy; Dr. Avilucea is a paid educational speaker for Zimmer-Biomet; Dr. Wyrick is a paid speaker for Smith and Nephew and is a paid consultant for Stryker; Dr. Archdeacon receives royalties and is a paid consultant for Stryker, receives royalties, financial support, or material support from SLACK incorporated, and is a board or committee member of the Orthopaedic Trauma Association. Drs. Schumaier, Sinha, and Le declare that they have no conflict of interest.

Ethical approval

This study was approved by the University of Cincinnati Institutional Review Board.

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Schumaier, A.P., Avilucea, F.R., Southam, B.R. et al. Terminal position of a tibial intramedullary nail: a computed tomography (CT) based study. Eur J Trauma Emerg Surg 46, 1077–1083 (2020). https://doi.org/10.1007/s00068-018-1000-1

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  • DOI: https://doi.org/10.1007/s00068-018-1000-1

Keywords

  • Distal tibia
  • Intramedullary nail
  • Alignment
  • Tibia fracture