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Semi-extended approach for tibial fractures yields better guide wire, IM nail position
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Results of a multicenter randomized trial indicate intramedullary fixation of isolated tibial fractures using a semi-extended approach yields better guide wire and final nail placement than using a standard approach.
The benefits of using the semi-extended approach also may lead to less risk for malunion and easier reduction of proximal third fractures.
“We feel the semi-extended approach leads to [achieving a] better guide wire position. [But] more significantly, we feel that it ends up with a significantly better final nail position,” Christopher Munro, MB, ChB, who is from the Department of Orthopaedics and Trauma at Aberdeen Royal Infirmary in Scotland, said during his presentation at the International Society for Fracture Repair Conference.
Though the data collection is not yet complete, he also noted, “Results do look promising with regard to the semi-extended approach in having less anterior knee pain [postoperatively].”
Images: Munro C
Similar demographics
Munro and colleagues studied 67 adult patients with no prior knee pathology who sustained an isolated traumatic tibial fracture and had 1-year follow-up. Investigators randomized 28 patients to undergo intramedullary nailing using the standard approach with the knee in 80° to 90° flexion and randomized 39 patients to have the semi-extension approach with the knee in 10° to 15° flexion.
The researchers determined the position of the nail and guide wire in relation to the axis of the tibia using radiographs and took intraoperative AP and lateral fluoroscopic images to note the locations of the intramedullary nail and guide wire. Munro noted that initially 94 patients were enrolled in the study, but several patients were eliminated after the images intended for use in analysis were determined to be poor quality.
The compared cohorts had similar demographics including gender distribution and age, with the standard group having a mean age of 37.4 years and the semi-extended group having a mean age of 41.8 years.
The mean deviation of the nail from the axis of the tibia on AP view images was 4.2° for the standard approach group compared to 2.4° for the semi-extended group. On lateral views, the mean deviation was 21.8° for the standard approach group and 17.9 ° for the semi-extended cohort. The position of the nail from the anterior cortex of the tibia, measured as a percentage of tibia width, was 19.3% for standard group and 23.4% for semi-extended cohort.
Other potential benefits
Munro also said the semi-extended position would allow for easier repair of complicated proximal third fractures, as the fracture angle would necessarily be reduced.
“Reduction of these proximal third fractures is difficult — if not to a higher standard technically — and we have problems with union,” he said, adding that the “standard position of traction meant to decrease flexion of the knee inherently led to displacement of these proximal third fractures [so] you are already starting with a losing battle.”
Though the data collection is incomplete, the results of the study could suggest that surgeons adopt the semi-extended approach to lessen a patient’s anterior knee pain, which was a long-lasting result in 25% to 40% of cases. Munro said this benefit may be linked to the protocol of sheathing the guide wire in a protective sleeve during semi-extended procedures, as opposed to free-handed guide wire positioning often used in standard cases. He theorized the sleeve served to protect the patella and patellar tendon from displacement. – by Katie Pfaff
- Reference:
- Munro C. Paper #37. Presented at: International Society for Fracture Repair Conference; May 14-17, 2014; New York City.
- For more information:
- Christopher Munro, MB, ChB, can be reached at the Department of Orthopaedics and Trauma, Aberdeen Royal Infirmary, Foresterhill Rd., Aberdeen AB252ZN, UK; email: cmunro@nhs.net.
Disclosure: Munro has no relevant financial disclosures. Smith & Nephew contributed to the study by overseeing data collection, data quality surveillance and coordination of combined clinical unit meetings.