ABSTRACT

Purpose. To assess the outcome of unreamed

intramedullary nailing through the lateralised entry
point using oblique proximal and biplanar distal
interlocking screws.
Methods. 15 men and 3 women aged 25 to 58 (mean,
37) years underwent unreamed intramedullary
nailing with oblique proximal and biplanar distal
interlocking screws for proximal third metaphyseal
tibial fractures. The entry point was kept proximal
to the tibial tuberosity and slightly lateral to midline.
Proximal locking was at 45 to the coronal and sagittal
planes. Biplanar distal locking was in the coronal and
sagittal planes.
Results. 16 patients had bone union within 20 (mean,
17; range, 1427) weeks; 2 underwent dynamisation for
delayed union. Three patients had valgus angulation
of <5; 2 had a loss of terminal knee fexion; 3 had
a loss of ankle dorsifexion; and 3 had shortening of
>0.5 cm. Functional outcomes were excellent in 13,
good in 4, and fair in one patient. No patient endured
Unreamed intramedullary nailing with oblique
proximal and biplanar distal interlocking
screws for proximal third tibial fractures
VK Singh,
1
Y Singh,
2
PK Singh,
3
RK Goyal,
2
H Chandra
2
1
Department of Trauma and Orthopaedics, Luton and Dunstable Hospitals NHS Foundation
2
Department of Trauma and Orthopaedics, SN Medical College and Hospital, Agra, India
3
Department of Neurovascular Surgery, Royal Hallamshire Hospital, Sheffeld, United Kingdom
Address correspondence and reprint requests to: Mr Vinay K Singh, Department of Trauma and Orthopaedics, Luton and Dunstable
Hospitals NHS Foundation Trust, Lewsey Road, Luton, LU4 0DZ, United Kingdom. E-mail: we.publish@googlemail.com
Journal of Orthopaedic Surgery 2009;17(1):23-7
neurovascular injury, compartment syndrome or
implant failure.
Conclusion. Unreamed intramedullary nailing with
oblique proximal and biplanar distal interlocking
screws for proximal third tibial fractures was effective
in preventing malalignment.
Key words: bone malalignment; fracture fxation,
intramedullary; tibial fractures
INTRODUCTION
Intramedullary nailing is a well-established treatment
modality for both simple and compound tibial
fractures. Its indication has extended from diaphyseal
fractures to proximal and distal metaphyseal fractures.
1

Valgus angulation and anterior displacement are
the 2 most common deformities.
13
Malalignment
is primarily due to discrepancy in size between the
tibial nail and the width of the tibial metaphysis as
well as displacing muscular forces acting around
the fracture.
1
The nail can translate laterally along
coronally placed uniplanar locking screws owing to
24 VK Singh et al. Journal of Orthopaedic Surgery
the absence of nail-bone contact.
4

A correct entry point is crucial in maintaining
the reduction and alignment of proximal third tibial
fractures. The conventional medial entry point is
associated with a high rate of malalignment.
1
Both
reamed or unreamed nailing achieve good results.
5

We assessed the outcome of unreamed intramedullary
nailing through the lateralised entry point using
oblique proximal and biplanar distal interlocking
screws.
MATERIALS AND METHODS
From May 2000 to October 2002, 15 men and 3 women
aged 25 to 58 (mean, 37) years underwent unreamed
intramedullary nailing with oblique proximal and
biplanar distal interlocking screws for proximal third
metaphyseal tibial fractures. 14 injured the right side
and 4 the left side. These injuries were secondary to
traffc accidents (n=15), falls from a height (n=2) and
football (n=1). 15 patients had open fractures (Gustilo
classifcation
6
type I=10, type II=3, and type IIIA=2);
3 patients had closed fractures according to Tscherne
classifcation
7
(grade-C2); 2 had segmental fractures
(Fig. 1). The mean time from injury to fxation was
29 (range, 6112) hours; in 15 patients fxation was
within 24 hours of injury; in 3 it was more delayed
because of associated head injury.
Ful l -l ength anteroposteri or and l ateral
radiographs of the tibia were taken to measure the
diameter of the medullary canal. Stainless steel solid
unreamed intramedullary nails of 8 mm (n=7) or 9
mm (n=11) in diameter were selected (Fig. 2). The leg
hanging technique was used without a tourniquet. A
4-cm incision was made over the middle part of the
patellar ligament (Fig. 3a). The entry point of nail
insertion was just proximal to the tibial tuberosity
and slightly lateral to the midline. The nail had 2
oblique proximal locking holes (anteromedial and
anterolateral) at an angle of 45 to the coronal and
sagittal planes, and locked with the help of a jig
(Fig. 3b). The distal screws were locked frst under
image guidance using a free hand technique with a
Steinmann pin (Fig. 3c).
Knee and ankle mobilisation and static
quadriceps exercises were started on postoperative
day 1. Patients were kept on partial weight bearing
with crutches for 6 to 8 weeks. Bone was defned as
united when radiographs showed bridging callus
(Fig. 4) and the patient could walk without pain.
Patients were assessed clinically, radiologically (axial
alignment), and functionally (using the Klemm and
Borner scoring system,
8
Table 1).
RESULTS
Patients were followed up for a mean of 38 (range, 2062)
months. 16 patients had bone union within 20 (mean,
17; range, 1427) weeks; 2 underwent dynamisation
for delayed union. Three patients had valgus
angulation of <5; none had anterior displacement of
the proximal fragment or anteroposterior angulation.
Two patients had a loss of terminal knee fexion (10
Figure 1 Patient 18: segmental fracture of the tibia.
Figure 2 The stainless steel solid unreamed intramedullary
nail and the proximal locking jig.
Vol. 17 No. 1, April 2009 Unreamed intramedullary nailing for proximal third tibial fractures 25
and 20); none had extension lag. Three patients had
a loss of ankle dorsifexion (15 in 2 and 5 in one);
3 had shortening of >0.5 cm; 2 had muscle atrophy
of >1 cm in circumference. Six patients complained
of pain which resolved and did not require implant
removal. Functional outcomes were excellent in 13,
good in 4, and fair in one patient. One patient had a
superfcial wound infection, which healed after oral
antibiotic therapy. No patient endured neurovascular
injury, compartment syndrome or implant failure
(Table 2).
DISCUSSION
Intramedullary nailing for proximal third tibial
fractures is associated with a high incidence of
malalignment,
1,2
attributable to muscular forces,
poor nail-bone contact, wrong entry portal, and
translation of the nail along single plane locking
screws.
1
Muscles of all 3 leg compartments tend to
pull small proximal fragments, predisposing the leg
to valgus and anterior bowing deformities.
1
A large
gap between the nail and upper tibial metaphysis
results in the absence of nail-cortex contact. The lack
of interference ft decreases the rigidity of nail-bone
construct and makes maintenance of reduction very
diffcult.
1

The proximal tibia is triangular in shape and is
Grade Description No. (%)
of patient
Excellent Full knee and ankle motion, no
muscle atrophy, normal alignment
13 (73)
Good Slight loss of knee and ankle
motion (<25%), muscle atrophy of
<2 cm, angular deformity of <5
4 (22)
Fair Moderate loss of knee and ankle
motion (25%), muscle atrophy
of 2 cm, angular deformity of
510
1 (6)
Poor Marked loss of knee and ankle
motion, marked muscle atrophy
and angular deformity
-
Table 1
Functional outcomes according to the Klemm and Borner
scoring system
8
Figure 4 Patient 18: anatomic bone union with no
malalignment at 22 weeks.
Figure 3 (a) The nail is
inserted from the lateralised
entry point through the
midline patellar splitting
approach. (b) Proximal
screws are locked with the
help of the locking jig. (c)
The distal screw is locked
using a free hand technique
with a Steinmann pin.
(a) (b)
(c)
26 VK Singh et al. Journal of Orthopaedic Surgery
narrower medially; the anteroposterior width of the
tibia is narrower on the medial side. A medial entry
point may result in a valgus deformity as the nail
abuts the medial cortex; varus deformity may occur
when the entry portal is too lateral. The nail entry
point for proximal-third tibial fractures should be
either neutral or slightly lateral to the midline.
1

Conventional tibial nails entail uniplanar
proximal and distal locking techniques. Mediolateral
screws in one plane may result in nail translation
causing valgus or varus malalignment.
4
Nails using
oblique proximal and biplanar distal locking were
alternatives to interlocking nails. In 145 tibial nail
fxations, 58% of proximal third tibial fractures were
malaligned, as compared to 7% of middle third and
8% of distal third fractures.
1
In 32 proximal third
tibial fractures treated with conventionally locked
nails, 27 (84%) had an angulation of >5 in the frontal
or sagittal plane, 19 (59%) had displacement of >1 cm,
and 8 (25%) had a loss of fxation.
2

To overcome the high rate of malalignment from
conventional tibial nailing, composite fxation was
advocated using a lateral plate with a medial external
fxator to achieve a stable buttress opposite to the
plate.
9
In 41 extra-articular comminuted proximal
tibial fractures treated with composite fxation, 2%
had malunion and 5% had infection. Intramedullary
nailing using Poller screws may prevent malalignment
in proximal and distal metaphyseal tibial fractures.
10

In 21 patients treated with Poller screws, the mean
varus and valgus alignment was -1 (-5 to 3) and
the mean antecurvatum-recurvatum alignment was
1.6 (-6 to 11).
10
In a cadaveric study, Poller screws
increased the mechanical stability of small-diameter
nails.
11
The use of an AO femoral distractor before
nailing of 14 proximal tibial fractures achieved a
mean anterior displacement of 3 (range, 017) mm
and a mean coronal plane alignment of 2 valgus
(range, 2 varus to 12 valgus).
12
In our series, the use
of the lateralised entry point and oblique proximal
and biplanar distal locking prevented nail translation
and achieved a low rate of malalignment.
The use of small-diameter unreamed nails
increases the risk of malunion, as well as nail
and locking screw fractures and thus the need for
reoperation.
13
In 50 patients treated for tibial shaft
fractures, 52% broke the interlocking screws, 4%
broke the nail, and 16% had malunion.
13
Unreamed
Patient
No.
Sex/
age
(years)
Mode
of
injury
Type of
injury
Time from
injury to
fxation
(hours)
Nail
size
(mm)
Time to
union
(weeks)
Malalign-
ment
Range of movement Pain Leg length
discrepancy
(cm)
Compli-
cations
1 M/30 RTA
*
Type I 14 9x32 17 4 valgus Loss of 15 ankle
dorsifexion
Knee - -
2 M/28 RTA Type II 8 9x34 14 - Full - - -
3 M/25 RTA Type I 99 8x34 16 - Loss of 15 ankle
dorsifexion
Ankle - -
4 M/58 Football C2 20 9x32 27 - Loss of 20 knee
fexion
- - -
5 M/35 RTA Type
IIIA
6 9x30 15 - Full - 0.5 Superfcial
infection
6 M/32 RTA Type I 12 9x32 19 - Loss of 10 knee
fexion
Knee - -
7 M/40 RTA Type II 8 9x32 16 - Full - - -
8 M/45 RTA Type I 12 8x34 16 - Full - - -
9 M/42 RTA Type
IIIA
14 9x34 18 4 valgus Full Knee - -
10 M/46 RTA Type I 13 8x34 15 - Loss of 5 ankle
dorsifexion
- 0.5 -
11 F/27 RTA Type II 110 9x34 16 - Full - - -
12 F/35 RTA Type I 12 8x34 15 - Full - - -
13 F/38 Fall C2 16 9x32 14 - Full Knee - -
14 M/42 RTA Type I 24 8x32 15 - Full - - -
15 M/26 Fall C2 112 8x32 15 - Full - - -
16 M/32 RTA Type I 9 9x34 25 3 valgus Full - - -
17 M/34 RTA Type I 18 9x34 18 - Full Ankle 0.5 -
18 M/55 RTA Type I 10 8x34 20 - Full - - -
Table 2
Patient characteristics and outcomes
* RTA denotes road traffc accident
Vol. 17 No. 1, April 2009 Unreamed intramedullary nailing for proximal third tibial fractures 27
nailing resulted in a higher rate of failure of
interlocking screws.
14
None of our patients broke
any locking screw or nail. Mechanical differences
between unreamed and reamed nails is most
signifcant in distal third tibial fractures.
15
Screw
failures are common in unreamed tibial nails for
distal third tibial fractures (specially in spiral or
oblique fractures).
1517
In 33 cases of tibial nailing,
patients with head injury had more implant failures,
due to postoperative agitation.
17
Three of our patients
with head injury did not have implant failure but
this number is too small to derive any conclusion.
Both reamed and unreamed nails have achieved
good results in type-I to type-IIIA compound tibial
fractures
14,15,1720
; no difference was noted in rates of
infection and bone union.
17

CONCLUSION
Unreamed intramedullary nailing for Gustilo type-I to
type-IIIA open fractures of the proximal metaphyseal
tibia was effective in preventing malalignment. The
neutral to slightly lateralised entry point and oblique
proximal and biplanar distal locking minimised the
risks of nail translation and malalignment.
REFERENCES
1. Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin
Orthop Relat Res 1995;315:2533.
2. Lang GJ, Cohen BE, Bosse MJ, Kellam JF. Proximal third tibial shaft fractures. Should they be nailed? Clin Orthop Relat Res
1995;315:6474.
3. Wolinsky PR, McCarty E, Shyr Y, Johnson K. Reamed intramedullary nailing of the femur: 551 cases. J Trauma 1999;46:3929.
4. Henley MB, Meier M, Tencer AF. Infuences of some design parameters on the biomechanics of the unreamed tibial
intramedullary nail. J Orthop Trauma 1993;7:3119.
5. Schemitsch EH, Kowalski MJ, Swiontkowski MF, Harrington RM. Comparison of the effect of reamed and unreamed locked
intramedullary nailing on blood fow in the callus and strength of union following fracture of the sheep tibia. J Orthop Res
1995;13:3829.
6. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-fve open fractures of long
bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:4538.
7. Tscherne H, Oestern HJ. A new classifcation of soft-tissue damage in open and closed fractures [in German]. Unfallheilkunde
1982;85:1115.
8. Klemm KW, Borner M. Interlocking nailing of complex fractures of the femur and tibia. Clin Orthop Relat Res 1986;212:89
100.
9. Bolhofner BR. Indirect reduction and composite fxation of extraarticular proximal tibial fractures. Clin Orthop Relat Res
1995;315:7583.
10. Krettek C, Stephan C, Schandelmaier P, Richter M, Pape HC, Miclau T. The use of Poller screws as blocking screws in
stabilising tibial fractures treated with small diameter intramedullary nails. J Bone Joint Surg Br 1999;81:9638.
11. Krettek C, Miclau T, Schandelmaier P, Stephan C, Mohlmann U, Tscherne H. The mechanical effect of blocking screws
(Poller screws) in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter
intramedullary nails. J Orthop Trauma 1999;13:5503.
12. Buehler KC, Green J, Woll TS, Duwelius PJ. A technique for intramedullary nailing of proximal third tibia fractures. J Orthop
Trauma 1997;11:21823.
13. McQueen MM, Christie J, Court-Brown CM. Compartment pressures after intramedullary nailing of the tibia. J Bone Joint
Surg Br 1990;72:3957.
14. Blachut PA, OBrien PJ, Meek RN, Broekhuyse HM. 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 1997;79:6406.
15. Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF. 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
2000;14:18793.
16. Whittle AP, Russell TA, Taylor JC, Lavelle DG. Treatment of open fractures of the tibial shaft with the use of interlocking
nailing without reaming. J Bone Joint Surg Am 1992;74:116271.
17. Keating JF, OBrien PJ, Blachut PA, Meek RN, Broekhuyse HM. Locking intramedullary nailing with and without reaming
for open fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am 1997;79:33441.
18. Shepherd LE, Costigan WM, Gardocki RJ, Ghiassi AD, Patzakis MJ, Stevanovic MV. Local or free muscle faps and unreamed
interlocked nails for open tibial fractures. Clin Orthop Relat Res 1998;350:906.
19. Kaltenecker G, Wruhs O, Heinz T. Primary stabilization of open fractures of the lower extremity with the interlocking
nailthe results of a study of 91 patients [in German]. Aktuelle Traumatol 1990;20:6773.
20. Court-Brown CM, Keating JF, McQueen MM. Infection after intramedullary nailing of the tibia. Incidence and protocol for
management. J Bone Joint Surg Br 1992;74:7704.