Treatment of distal metaphyseal tibia fractures with involvement of the ankle by combination of locked intramedullary nailing and covered screw osteosynthesis

Fractures of the distal meta physis of the tibia often include an extension into the ankle. Intramedullary nailing combined with covered screw osteosy nthesis should reduce the high incidence of soft tissue and ankle problems and should be an alternative to open plate fixation, with good ultimate fun ctional outcome. Between January 1993 and December 1995, a prospective stud y on 49 patients with distal metaphyseal tibia fracture and involvement of the ankle was performed. All the fractures were treated with intramedullary nailing combined with covered screw osteosynthesis, and plate fixation in cases of fibula fractures. There were 27 men and 22 women with an average a ge of 46.4 +/- 12.7 years (range 21-90). In most studies of the use of intr amedullary nailing in distal tibial fractures the classification has been i nadequate. therefore a new classification according to Robinson et al. (199 5) was used: 10 fractures were type ii B (20.4%), 13 were type II C (26.5 % ), and 26 patients suffered a combination of type It B and type II C (53.1 %). This fracture type was defined as type II D for use in this study. The severity of soft tissue injury was recorded using the Gustilo system in cas e of open (n = 19) and the Tscherne system in case of closed fractures (n = 30). In 31 patients distal tibia fracture was accompanied by a fracture of the fibula, which was first stablized using a plate. For reconstruction of the distal articular surface, covered screw osteosynthesis was done. At th e next step intramedullary nails were inserted and were statically locked p roximally and distally. From January 1993 to February 1994 the reamed AO st andard nail was used. After introduction of the unreamed tibial nail (UTN) all fractures were treated by this implant. Full load on the operated leg w as allowed after 8 weeks. Union of the fracture was assessed by standard ra diological and clinical criteria. Misalignment was defined as more than 5 d egrees of angular rotation. Further surgery due to a valgus deformity in th e ankle joint had to be done in three cases. There were no deep infections. Three patients had a superficial infection in the ankle area, but surgical debridement was not necessary. A leg shortening was found in 4 cases, but it was less than 1 cm in every case. Therefore, surgical correction was not done. Patients were reviewed at intervals of 2, 6, and 12 weeks, and after 6,and at least 12 months. All 49 patients were finally reviewed after an a verage time of 15.7 months (range 12-38). Bone fusion was reached 12.8 week s (range 9-21) after the operative treatment. A specific assessment of the ankle symptoms was made using the score of Olerud and Molander (1984). In 2 9 patients excellent results were recorded. A satisfactory result was attai ned with 17 patients and just 3 patients were found to be unsatisfactory. A lthough proximity of distal tibia fracture to the ankle makes the treatment more complicated than for fractures of the tibial diaphysis, closed intram edullary nailing combined with covered screw fixation is a good alternative to open reduction and plate fixation. The major advantages are closed proc edure and simplified interlocking techniques. Therefore, closed intramedull ary nailing combined with covered screw fixation is a safe and effective me thod of managing this type of fracture.