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CASE REPORTS

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Nailing of a Proximal Third Tibial Shaft Fractures Using CorticalSubstitution Screws

Melissa M. Gross, MDa and Brian M. Weatherford, MDb

Summary: The proximal third tibial shaft continues to be aregion fraught with fixation challenges. The deforming forcesacting on the proximal tibia and the broad metaphyseal diameterin relation to the nail heavily influence the surgeon’s ability toobtain reduction, maintain alignment, and achieve union whileallowing for early range of motion and weight-bearing. Advancesin nail design and refinement of surgical technique have led toincrease utilization of nailing for proximal tibial metaphysealfractures. Intraoperative use of OTA/AO distractors or externalfixators, percutaneous clamps, unicortical plates for provisionalreduction, and blocking screws are routinely used. This case out-lines the use of threaded wires and interlocking screws both asintraoperative reduction aids and cortical substitution devices torestore the mechanical axis of the limb and prevent late loss ofreduction.

Key Words: proximal tibia, intramedullary nailing, blockingscrews, cortical substitution

INTRODUCTIONTibial shaft fractures are well established as the most common

long bone fractures with proximal third diaphyseal fractures

(OTA/AO 42)1 accounting for approximately 5%–11% of tibialfractures.2,3With a thin soft tissue envelope along the anteromedialaspect of the tibia, many of these injuries present as open fractureswith significant soft tissue compromise. Compartment syndromemust always be considered with an overall incidence of 9% of tibialfractures.4

The goal of surgical intervention is to obtain union andsimultaneously restore the mechanical axis of the limb. The idealsurgical construct for this injury pattern would minimize damage tothe soft tissue envelope while allowing for early weight-bearingand functional range of motion.

Implant selection includes external fixation, plate–screw con-structs, and intramedullary (IMN) devices.5–8 External fixation isbest used as a temporizing measure rather than definitive man-agement except for very select circumstances. Plate–screw con-structs are particularly useful for proximal fracture patterns withcomplex articular involvement. Plating constructs may, however,cause further injury to the already compromised soft tissue enve-lope. Typical plate constructs are load-bearing and therefore do notallow for immediate or early weight-bearing. IMN devices can becontraindicated because of the presence of previous implants orpreexisting bony deformity.5 Treatment must be individualizedbased on the injury pattern, patient factors, and the surgeon’sexperience.

IMN of proximal third tibial shaft fractures offer the uniqueadvantage of early weight-bearing and range of motion via a load-sharing device. Early implant designs failed to address the broadmetadiaphyseal canal and the deforming forces unique to proximalthird fractures. Rates ofmalalignment were reported to be as high as58%–84% with early implant designs, leading many surgeons tolimit IMN in favor of plating.2,6,9 Advances in instrumentationfocusing on the ideal anatomic starting point,10 proximal nailbend,11 and increased proximal and distal fixation12 have expandedthe indications for fractures previously thought to be not amenableto medullary nailing. The following is a case report of an openproximal third tibial shaft fracture treated with the Tibial Nail

From the aUniversity of Illinois at Chicago, Chicago, IL; and bIllinois Bone& Joint Institute, Glenview, IL.

B. M. Weatherford: Consultant for Depuy Synthes and Lineage Medical.The remaining author reports no conflict of interest.

Reprints: Brian M. Weatherford, MD, Illinois Bone & Joint Institute, 2401RavineWay, Suite 200, Glenview, IL 60025 (e-mail: bweatherford@ibji.com).The views and opinions expressed in this case report are those of theauthors and do not necessarily reflect the views of the editors of Journalof Orthopaedic Trauma or DePuy Synthes.

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DOI: 10.1097/BOT.0000000000002326

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Advanced (TNA; DePuy Synthes, Monument, CO) system with 3-month follow-up.

Patient InformationA 23-year-old healthy man presented to our institution as a

trauma activation after a high-speed motor vehicle collision. Thepatient was hemodynamically unstable upon arrival and wasurgently transferred to the operating room for exploratory laparot-omy and bowel resection. His musculoskeletal injuries included aleft type III open proximal tibial shaft fracture (Figs. 1A–D), a rightclosed, segmentally comminuted femoral shaft fracture and a rightposterior process talus fracture. He received appropriate antibioticsfor his open fracture andwas placed into well-padded splints for hisextremity injuries. Per the recommendations of the trauma surgeryservice, treatment of his open fracture was delayed as the patientremained critically ill. Distal femoral skeletal traction was appliedin the intensive care unit (ICU) to maintain length of the rightfemoral shaft fracture. The patient received appropriate resuscita-tion and the following day was cleared for operative treatment ofhis extremity injuries. The initial goals of treatment were to performappropriate debridement of the open fracture site, followed by pro-visional versus definitive stabilization of his extremity injuries.Intraoperatively, open communication was maintained with theanesthesia service to ensure the patient remained appropriatelyresuscitated throughout the surgery. Fixation of the left tibia wasperformed using the TNA (DePuy Synthes) system.

Surgical TechniqueThe patient was transferred from the surgical ICU intubated and

in stable condition. General anesthesia was maintained by theanesthesia service. He was then positioned supine on a radiolucenttable, and the left lower extremity was prepped and draped in astandard sterile fashion. We verified that antibiotic coverage for hisopen fracture had been continued. Two distinct open wounds over

the proximal and mid-diaphyseal aspects of the tibia wereidentified. The open fracture wounds were extended to gain accessto the full zone of injury to perform appropriate debridement. Athorough and systematic sharp debridement was performed toremove any nonviable tissue. The wound was then irrigated with atotal of 9 L saline. The open fracture site appeared appropriatelydebrided of necrotic tissue and the patient remained in stablecondition. Therefore, we proceededwith definitive internal fixationof the tibia.

Reduction of the tibia was performed with longitudinal tractionfollowed by clamp application (Fig. 2A). The posteromedial cortexremained intact and was therefore used as a read to reduction.Appropriate restoration of length, rotation, and alignment was ver-ified on biplanar fluoroscopy before proceeding with medullarynailing of the tibia. To facilitate intraoperative imaging and mini-mize risk of fracture deformation, we elected to use a semi-extended/suprapatellar nailing technique.

A bump was placed under the knee joint to flex the kneeapproximately 30 degrees. The patient’s patellar mobility was as-sessed and found to be appropriate. A 3- to 4-cm incision was thenmade above the superior pole of the patella. The quadriceps tendonwas divided sharply in its midline. The retropatellar space wasdeveloped bluntly. Thewire guide (DePuy Synthes) was then intro-duced atraumatically into the patellofemoral joint (Fig. 2B). Theappropriate starting point was verified on anterior posterior andlateral views to be at themedial aspect of the lateral tibial eminence,just anterior to the articular surface, and in line with the anteriorcortex. The protection sleeve was then introduced over the wireguide into the joint and the 12-mm entry reamer was used to openthe proximal tibial canal. A ball-tipped guidewire was advancedand noted to skive along the posterior cortex before exiting throughthe distal aspect of the fracture. Two 2.5-mm terminally threadedSchanz pins were placed as blocking wires both lateral and poste-rior to redirect the guidewire down the central access of the tibial

FIGURE 1. A–D, anterior posterior andlateral plain radiographs demonstratinga proximal third tibial shaft fracture(OTA/AO 42).

Gross and Weatherford

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canal (Figs. 2C–E). The guidewire was then impacted into the distaltibial metaphysis in line with the lateral third of the tibial plafondand centrally on the lateral view. Sequential reaming to 11.5 mmwas performed taking care not to ream across the comminuted zoneof fracture.

A 103 400-mm TNA (DePuy Synthes) was then inserted overthe ball-tipped guidewire. The blocking wires maintained appro-priate trajectory of the nail (Fig. 2F). With the external targetingguide, 4 proximal interlocking screws (2 medial to lateral, obliqueanteromedial and anterolateral) were placed (Fig. 2G). Two distalinterlocking screws were placed via freehand perfect circle tech-nique. To ensure appropriate maintenance of reduction, the termi-nally threaded Schanz pins were then exchanged for 5-mminterlocking screws to serve as cortical substitution screws bothposterior and lateral to the nail in the proximal segment (Figs.2H, I). Final fluoroscopic images were obtained verifying appro-priate restoration of length, rotation and alignment. This was fur-ther confirmed with intraoperative plain radiographs (Figs. 3A–D).

An additional 1 L of saline was irrigated through the openfracture site. Vancomycin topical powder was placed. The open

wounds were closed with interrupted 2-0 nylon in a modifiedAllogwer Donati technique. Soft dressings were applied and thepatient was then placed into a pneumatic cam boot with the ankle inneutral dorsiflexion.

After discussion with the anesthesia service, it was determinedthat the patient was not hemodynamically optimized for additionalinternal fixation of the right femoral shaft fracture. Therefore, atemporizing external fixator was applied to the right femur.

Postoperative CourseThe patient remained intubated but in stable condition and was

transferred back to the surgical ICU. He returned to the operatingroom 2 days later for medullary nail fixation of his right femurfracture. Open reduction internal fixation of his right talus fracturewas performed an additional 10 days later. He was instructed to beweight-bearing as tolerated on the left lower extremity and non–weight-bearing on the right lower extremity secondary to the righttalus fracture. The patient’s postoperative course was complicatedby a right lower lobe pneumonia leading to prolonged intubationand tracheostomy placement. He also displayed encephalopathic

FIGURE 2. Intraoperative fluoroscopic images showing the proximal tibia after provisional reduction with (A) clamp application and(B) introduction of Synthes guide for wire placement. C–E, Schanz pins placed as blocking wires both lateral and posterior to redirectthe guidewire down the central access of the tibial canal. F, Insertion of nail while blocking wires maintain appropriate nail trajectory.G, Placement of 4 proximal interlocking screws before (H–I) exchanging Schanz pins for 5-mm interlocking screws to serve as corticalsubstitution screws.

Nailing of a Proximal Third Tibial Shaft Fractures

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findings despite negative CT head. He subsequently discharged toinpatient rehab and ultimately discharged home at 10 weeks post-operatively. The patient presented to the office at 14 weeks post-operatively, ambulating without assistive device (Figs. 4A, B).

Radiographs demonstrated progressive bridging of his fracture sitewith maintenance of alignment.

DISCUSSIONIn this case, we present a young polytrauma patient with a type

III open proximal tibial shaft fracture and contralateral femoralshaft and talus fractures. We opted to perform internal fixationusing a medullary nail with multiple proximal fixation options toobtain a construct with stable fixation that maintained alignmentwhile minimizing further soft tissue injury.

The proximal third tibial shaft continues to be a region fraughtwith fixation challenges. High rates of apex anterior and valgusmalalignment previously led many surgeons to limit their indica-tions for IMN.2,6,9,11,13 Reasons for malalignment are multifacto-rial and include nail design,11 inappropriate starting point or nailtrajectory,9,10 soft tissue deforming forces,6,14 and the broad meta-diaphyseal diameter of the proximal tibia in relation to thenail.2,8,15,16 Freeman9 radiographically examined 133 tibial nailsand found 16 (12%) with malalignment .5 degrees in any plane.Proximal third fractures had a significantly higher incidence ofmalunion (58%) compared with middle (7%) and distal-third(8%) fractures. The authors attributed failures to increased entranceangle and stressed the importance of neutral or lateral portal toovercome valgus deformity. In this cohort, many nails were un-locked or dynamically locked. The cohort by Lang et al2 consistedof 32 proximal third fractures, ofwhich 27 (84%)weremal-reducedat final follow-up. In this sample, 59% had fracture displacement.1 cm and 25% had loss of fixation associated with a single prox-imal locking screw.

The advantages of IMN have led to increased emphasis onoperative technique to achieve acceptable reduction and union.Solutions to overcome malalignment include nail design modifi-cations (more proximal Herzog curve, multiple proximal screwoptions),11 lateral starting points2,9,13 within a defined “safezone,”10 entrance angles in line with the anterior cortex, semi-

FIGURE 3. A–D, Immediate post-operative films demonstrating restora-tion of length and alignment.

FIGURE 4. A, B, anterior posterior and lateral radiographs at14 weeks after surgical treatment demonstrating maintenance oflength and alignment with progressive fracture healing.

Gross and Weatherford

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extended positioning10,14 (including suprapatellar or lateral para-patellar), and the use of OTA/AO distractors,13 percutaneousclamps,8 and unicortical plates for provisional reduction.17,18

We routinely will use all the described tools to obtain andmaintain reduction of proximal third tibial fractures includingOTA/AO distractors, temporary external fixators, and blockingdevices. In situations where blocking wires are used to direct thenail pathway, these will be routinely exchanged for interlockingscrews (cortical substitution screws) to increase stiffness and limitthe risk of loss of alignment. Krettek et al16 initially described theplacement of unicortical or bicortical locking bolts in the cortexadjacent to the nail to correct angulation created when passing thenail. Since then, several articles have outlined the placement ofpercutaneous blocking screws, wires, or Steinman pins to guidethe path of the guide wire and reamers before nail place-ment.7,14,16,19,20 Typically blocking screws are placed in the prox-imal fragment in the concavity of deformity. To limit apex anteriorangulation, blocking screws placed in the posterior aspect of thetibia in the coronal plane will guide the nail toward the anteriorcortex. Similarly, sagittally oriented screws lateral to the centralaxis of the tibia overcome valgus angulation. Ricci et al19 evaluated12 proximal tibia fractures. In his cohort, only 1 had postoperativevalgus malalignment of 6 degrees; however, a blocking screw wasused posteriorly but not laterally.

Screws placed appropriately can function as a substitute for adeficient cortex in the setting of cortical comminution or acapacious metaphyseal canal. When used in this manner, surgeonscan control the environment in which the nail is placed bynarrowing the metaphyseal diameter in line with the medullarycanal. The introduction of screws adjacent to the IMN significantlyincrease biomechanical stability by enhancing the bone–nail inter-face.15 Krettek et al15 placed medial and lateral blocking screws in10 cadaveric specimens with tibial IMN for proximal fractures.When compared with 2 medial–lateral interlocking screws, theaddition of blocking screws increased fracture stiffness by 25%.

Cinats et al18 retrospectively studied 53 proximal tibia fracturestreated with a combination of IMN and provisional plate fixationwith or without blocking screws. At 1-year follow-up, loss ofreduction occurred in 15% of fractures treated with IMN only,0% when plate was used and retained, and 18% when the platewas removed after IMN placement. Although these data were notstatistically significant (P 5 0.29), they clinically suggest thatremoval of provisional plates can lead to postoperative loss ofreduction. The authors attributed the lack of blocking screws usedin the plate removal group contributed to postoperative malalign-ment (P 5 0.002).

CONCLUSIONSThe deforming forces acting on the proximal tibia and the broad

metadiaphyseal diameter in relation to the nail heavily influence thesurgeon’s ability to obtain reduction, maintain alignment, andachieve bony union while allowing for early range of motion andweight-bearing. Multiple adjuncts can assist with maintainingalignment including a nail design with multiple proximal pointsof fixation, intraoperative use of distractors or external fixators,unicortical plates, and blocking screws. Blocking screws can beused as both intraoperative reduction aids and cortical substitutiondevices to avoid postoperative malalignment. Further research is

needed to evaluate use of interlocking screws for cortical substitu-tion and the incidence of malunion and late loss of reduction.

REFERENCES1. Meinberg EG, Agel J, Roberts CS, et al. Fracture and dislocation classi-fication compendium-2018. J Orthop Trauma. 2018;32(suppl 1):S1–S170.

2. Lang GJ, Cohen BE, Bosse MJ, et al. Proximal third tibial shaft fractures.Should they be nailed? Clin Orthop Relat Res. 1995:64–74.

3. Court-Brown CM, Bugler KE, Clement ND, et al. The epidemiology ofopen fractures in adults. A 15-year review. Injury. 2012;43:891–897.

4. Shuler FD, Dietz MJ. Physicians’ ability to manually detect isolated ele-vations in leg intracompartmental pressure. J Bone Joint Surg Am. 2010;92:361–367.

5. Lourenço P. AO Principles of Fracture Management: Vol. 1: Principles,Vol. 2: Specific Fractures. New York, NY: Thieme Medical Publishers,Inc; 2017.

6. Hiesterman TG, Shafiq BX, Cole PA. Intramedullary nailing of extra-articular proximal tibia fractures. J Am Acad Orthop Surg. 2011;19:690–700.

7. Bono CM, Levine RG, Rao JP, et al. Nonarticular proximal tibia fractures:treatment options and decision making. J Am Acad Orthop Surg. 2001;9:176–186.

8. Lee C, Zoller SD, Perdue PW Jr, et al. Pearls and pitfalls with intra-medullary nailing of proximal tibia fractures. J Am Acad Orthop Surg.2020;28:66–73.

9. Freedman EL, Johnson EE. Radiographic analysis of tibial fracture mala-lignment following intramedullary nailing. Clin Orthop Relat Res. 1995:25–33.

10. Tornetta P III, Collins E. Semiextended position of intramedullary nailingof the proximal tibia. Clin Orthop Relat Res. 1996:185–189.

11. Henley MB, Meier M, Tencer AF. Influences of some design parameterson the biomechanics of the unreamed tibial intramedullary nail. J OrthopTrauma. 1993;7:311–319.

12. Laflamme GY, Heimlich D, Stephen D, et al. Proximal tibial fracturestability with intramedullary nail fixation using oblique interlockingscrews. J Orthop Trauma. 2003;17:496–502.

13. Buehler KC, Green J, Woll TS, et al. A technique for intramedullarynailing of proximal third tibia fractures. J Orthop Trauma. 1997;11:218–223.

14. Stinner DJ, Mir H. Techniques for intramedullary nailing of proximal tibiafractures. Orthop Clin North Am. 2014;45:33–45.

15. Krettek C, Miclau T, Schandelmaier P, et al. The mechanical effect ofblocking screws (‟Poller screws”) in stabilizing tibia fractures with shortproximal or distal fragments after insertion of small-diameter intramedul-lary nails. J Orthop Trauma. 1999;13:550–553.

16. Krettek C, Schandelmaier P, Tscherne H. Nonreamed interlocking nailingof closed tibial fractures with severe soft tissue injury. Clin Orthop RelatRes. 1995:34–47.

17. Dunbar RP, Nork SE, Barei DP, et al. Provisional plating of Type III opentibia fractures prior to intramedullary nailing. J Orthop Trauma. 2005;19:412–414.

18. Cinats DJ, Perey B, Moola F, et al. Plate-assisted intramedullary nailing ofproximal third tibia fractures. J Orthop Trauma. 2020;34:321–326.

19. Ricci WM, O’Boyle M, Borrelli J, et al. Fractures of the proximal third ofthe tibial shaft treated with intramedullary nails and blocking screws.J Orthop Trauma. 2001;15:264–270.

20. Krettek C, Stephan C, Schandelmaier P, et al. The use of Poller screws asblocking screws in stabilising tibial fractures treated with small diameterintramedullary nails. J Bone Joint Surg Br. 1999;81:963–968.

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Nailing of a Proximal Third Tibial Shaft Fractures

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