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A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN)

  • Trauma Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

The aim of this study was to present clinical experience and outcomes of intramedullary nailing of proximal, midshaft and distal tibia fractures with the Expert Tibia Nail (ETN; Synthes GmbH, Switzerland), an implant offering a wide range of proximal and distal locking options in multiple planes to increase stability of the implant and bone construct.

Patients and methods

180 patients with 185 tibia fractures were enclosed between July 2004 and May 2005 from ten trauma units (Levels I, II and III) and treated with intramedullary reamed and unreamed nailing with the ETN. Patients attended examinations at 12 weeks and 1 year. The occurrence of postoperative complications was documented as well as the outcomes of fracture healing, primary and secondary malalignment, implant failure, rate of infection and the need for reoperation.

Results

The 1-year follow-up rate was 81 %. At 1 year, the prevalence of delayed union was 12.2 % and higher for open fractures (18.2 %) compared to closed fractures (9.7 %). According to the fracture location, the percentage of delayed union was 5.9, 16.7 and 10.5 % in proximal third, midshaft and distal third cases, respectively. Patients with a plated fibula fracture had an eightfold higher risk of delayed union. The rate of malalignment >5° in any plane 1 year after surgery was 5.5 %. Proximal third fractures were at a higher risk of postoperative malalignment (17.6 %). The rate of secondary malalignment was 1.4 %. The risk of unplanned reoperation was 9.2 %.

Conclusion

Intramedullary ETN fixation of tibia fractures results in low rates of delayed union, primary and secondary malalignment, implant-related complications, and secondary surgery. Fibula plating had a negative effect on the healing of the tibia.

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References

  1. Batten RL, Donaldson LJ, Aldridge MJ (1978) Experience with the AO method in the treatment of 142 cases of fresh fracture of the tibial shaft treated in the UK. Injury 10:108–114

    Article  PubMed  CAS  Google Scholar 

  2. Blachut PA, O’Brien PJ, Meek RN, Broekhuyse HM (1997) Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am 79:640–646

    PubMed  CAS  Google Scholar 

  3. Chiu FY, Lo WH, Chen CM, Chen TH, Huang CK (1996) Unstable closed tibial shaft fractures: a prospective evaluation of surgical treatment. J Trauma 40:987–991

    Article  PubMed  CAS  Google Scholar 

  4. Court-Brown CM, Will E, Christie J, McQueen MM (1996) Reamed or unreamed nailing for closed tibial fractures. A prospective study in Tscherne C1 fractures. J Bone Joint Surg Br 78:580–583

    PubMed  CAS  Google Scholar 

  5. Finkemeier CG, Schmidt AH, Kyle RF, Templeman BC, Varecka TF (2000) A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma 14:187–193

    Article  PubMed  CAS  Google Scholar 

  6. Littenberg B, Weinstein LP, McCarren M, Mead T, Swiontkowski MF, Rudicel SA, Heck D (1998) Closed fractures of the tibial shaft. A meta-analysis of three methods of treatment. J Bone Joint Surg Am 80:174–183

    PubMed  CAS  Google Scholar 

  7. Mosheiff R, Safran O, Segal D, Liebergall M (1999) The unreamed tibial nail in the treatment of distal metaphyseal fractures. Injury 30:83–90

    Article  PubMed  CAS  Google Scholar 

  8. Ahlers J, von Issendorff WD (1992) Incidence and causes of malalignment following tibial intramedullary nailing. Unfallchirurg 18:31–36

    Article  CAS  Google Scholar 

  9. Bhandari M, Audige L, Ellis T, Evidence-Based Orthopaedic Trauma Working Group (2003) Operative treatment of extra-articular proximal tibial fractures. J Orthop Trauma 17:591–595

    Article  PubMed  Google Scholar 

  10. Freedman EL, Johnson EE (1995) Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res 315:25–33

    PubMed  Google Scholar 

  11. Hansen M, Mehler D, Hessmann MH, Blum J, Rommens PM (2007) Intramedullary stabilization of extraarticular proximal tibial fractures: a biomechanical comparison of intramedullary and extramedullary implants including a new proximal tibia nail (PTN). J Orthop Trauma 21:701–709

    Article  PubMed  Google Scholar 

  12. Lang GJ, Cohen BE, Bosse MJ, Kellam JF (1995) Proximal third tibial shaft fractures. Should they be nailed? Clin Orthop Relat Res 315:64–74

    PubMed  Google Scholar 

  13. Im GI, Tae SK (2005) Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation. J Trauma 59:1219–1223

    Article  PubMed  Google Scholar 

  14. Robinson CM, McLauchlan GJ, McLean IP, Court-Brown CM (1995) Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br 77:781–787

    PubMed  CAS  Google Scholar 

  15. Hansen M, Mehler D, Voltmer W, Rommens PM (2002) The extraarticular proximal tibial fractures. Unfallchirurg 105:858–872

    Article  PubMed  CAS  Google Scholar 

  16. Müller ME, Nazarian S, Koch P, Schatzker J (1990) The comprehensive classification of fractures of long bones. Springer, Berlin

    Book  Google Scholar 

  17. Buehler KC, Green J, Woll TS, Duwelius PJ (1997) A technique for intramedullary nailing of proximal third tibia fractures. J Orthop Trauma 11:218–223

    Article  PubMed  CAS  Google Scholar 

  18. Hansen M, El Attal R, Blum J, Blauth M, Rommens PM (2009) Tibiamarknagelung mit dem Expert Tibia Nagel [Intramedullary nailing of the tibia with the expert tibia nail]. Oper Orthop Traumatol 21(6):620–635

    Article  PubMed  Google Scholar 

  19. Gustilo RB, Anderson JT (1976) Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 58:453–458

    PubMed  CAS  Google Scholar 

  20. Gustilo RB, Mendoza RM, Williams DN (1984) Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 24:742–746

    Article  PubMed  CAS  Google Scholar 

  21. Tscherne H, Oestern HJ (1982) A new classification of soft-tissue damage in open and closed fractures). Unfallheilkunde 85:111–115

    PubMed  CAS  Google Scholar 

  22. Bone LB, Kassman S, Stegemann P, France J (1994) Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails. J Orthop Trauma 8:45–49

    Article  PubMed  CAS  Google Scholar 

  23. Markmiller M, Tjarksen M, Mayr E, Rüter A (2000) The unreamed tibia nail. Multicenter study of the AO/ASIF. Osteosynthesefragen/Association for the study of internal fixation. Langenbecks Arch Surg 385:276–283

    Article  PubMed  CAS  Google Scholar 

  24. Riemer BL, Miranda MA, Butterfield SL, Burke CJ 3rd (1995) Nonreamed nailing of closed and minor open tibial fractures in patients with blunt polytrauma. Clin Orthop Relat Res 320:119–124

    PubMed  Google Scholar 

  25. Court-Brown CM, Keating JF, Christie J, McQueen MM (1995) Exchange intramedullary nailing. Its use in aseptic tibial nonunion. J Bone Joint Surg Br 77:407–411

    PubMed  CAS  Google Scholar 

  26. Koval KJ, Clapper MF, Brumback RJ, Ellison PS Jr, Poka A, Bathon GH et al (1991) Complications of reamed intramedullary nailing of the tibia. J Orthop Trauma 5:184–189

    Article  PubMed  CAS  Google Scholar 

  27. Mohammed A, Saravanan R, Zammit J, King R (2008) Intramedullary tibial nailing in distal third tibial fractures: distal locking screws and fracture non-union. Int Orthop 32:547–549

    Article  PubMed  Google Scholar 

  28. Muller CA, Dietrich M, Morakis P, Pfister U (1998) Clinical results of primary intramedullary osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft fractures. Unfallchirurg 101:830–837

    Article  PubMed  CAS  Google Scholar 

  29. Drosos GI, Bishay M, Karnezis IA, Alegakis AK (2006) Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures. J Bone Joint Surg Br 88:227–231

    Article  PubMed  CAS  Google Scholar 

  30. Lee Q, Zeng BF, Luo CF, Wang JW, Lu NJ (2006) Backstroke technique: an effective way to improve the healing of tibia fracture. Int Orthop 30:329

    Article  PubMed  Google Scholar 

  31. LaFlamme GY, Heimlich D, Stephen D, Kreder HJ, Whyne CM (2003) Proximal tibial fracture stability with intramedullary nail fixation using oblique interlocking screws. J Orthop Trauma 17:496–502

    Article  PubMed  CAS  Google Scholar 

  32. Egol KA, Weisz R, Hiebert R, Tejwani NC, Koval KJ, Sanders RW (2006) Does fibular plating improve alignment after intramedullary nailing of distal metaphyseal tibia fractures? J Orthop Trauma 20:94–103

    Article  PubMed  Google Scholar 

  33. Obremskey WT, Medina M (2004) Comparison of intramedullary nailing of distal third tibial shaft fractures: before and after traumatologists. Orthopedics 27:1180–1184

    PubMed  Google Scholar 

  34. Shen WJ, Shen YS (1993) Fibular nonunion after fixation of the tibia in lower leg fractures. Clin Orthop Relat Res 287:231–232

    PubMed  Google Scholar 

  35. Stegemann P, Lorio M, Soriano R, Bone L (1995) Management protocol for unreamed interlocking tibial nails for open tibial fractures. J Orthop Trauma 9:117–120

    Article  PubMed  CAS  Google Scholar 

  36. DeLee JC, Heckman JD, Lewis AG (1981) Partial fibulectomy for ununited fractures of the tibia. J Bone Joint Surg Am 63:1390–1395

    PubMed  CAS  Google Scholar 

  37. Sorensen KH (1969) Treatment of delayed union and non-union of the tibia by fibular resection. Acta Orthop Scand 40:92–104

    Article  PubMed  CAS  Google Scholar 

  38. Vallier HA, Le TT, Bedi A (2008) Radiographic and clinical comparisons of distal tibia shaft fractures (4 to 11 cm proximal to the plafond): plating versus intramedullary nailing. J Orthop Trauma 22:307–311

    Article  PubMed  Google Scholar 

  39. Larsen LB, Madsen JE, Hoiness PR, Ovre S (2004) Should insertion of intramedullary nails for tibial fractures be with or without reaming? A prospective, randomized study with 3.8 years’ follow-up. J Orthop Trauma 18:144–149

    Article  PubMed  Google Scholar 

  40. Bhandari M, Guyatt G, Tornetta P 3rd, Schemitsch EH, Swiontkowski M, Sanders D et al (2008) Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am 90:2567–2578

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors would like to thank the following surgeons for their participation in collecting data for this study: Prof. P. Giannoudis (Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom); Dr. J. Spycher (Hospital Interlaken, Interlaken, Switzerland); and Dr. R. K. Simmermacher (University Hospital Utrecht, Utrecht, Netherlands. The authors wish to thank the AO Clinical Investigation and Documentation team for their invaluable support in the analysis (Laurent Audigé, PhD) and final revision (Melissa Wilhelmi, PhD) of this manuscript.

Conflict of interest

The authors declare that they have no conflict of interest.

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Authors and Affiliations

  1. Department of Trauma Surgery and Sports Medicine, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria

    Rene Attal & R. Rosenberger

  2. Center for Musculoskeletal Surgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany

    M. Hansen & P. M. Rommens

  3. Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland

    M. Kirjavainen

  4. Department of Trauma and Reconstructive Surgery, Charité Campus Virchow, Humboldt University of Berlin, Berlin, Germany

    H. Bail

  5. Department of Orthopaedic and Trauma Surgery, University Hospital Freiburg, Freiburg, Germany

    T. O. Hammer

  6. Berufsgenossenschaftliche Unfallklinik, Tübingen, Germany

    D. Höntzsch

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  1. Rene Attal
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Correspondence to Rene Attal.

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Attal, R., Hansen, M., Kirjavainen, M. et al. A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN). Arch Orthop Trauma Surg 132, 975–984 (2012). https://doi.org/10.1007/s00402-012-1502-y

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  • DOI: https://doi.org/10.1007/s00402-012-1502-y

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