|Year : 2021 | Volume
| Issue : 4 | Page : 173-178
Outcomes of intramedullary steinmann pin fixation for concurrent fibula fracture in comminuted tibia shaft or distal metaphyseal tibia fractures
Po-Yu Lee, Chiu-Ming Chen, Hui-Sen Tseng, Jui-Jung Yang
Department of Orthopaedic Surgery, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
|Date of Submission||29-Jun-2020|
|Date of Decision||29-Jul-2020|
|Date of Acceptance||15-Sep-2020|
|Date of Web Publication||25-Dec-2020|
Dr. Jui-Jung Yang
Department of Orthopedics, National Defense Medical Center, Tri-service General Hospital, 325 Cheng-Gong Road Section 2, Taipei 114
Source of Support: None, Conflict of Interest: None
Background: Fracture of the tibia shaft accounts for 17% of lower extremity fractures, with concurrent fibula fracture in about 78% of these cases. Intramedullary fixation for fibula fractures can restore fibula alignment and thus facilitate fracture reduction, especially in cases with comminuted shaft or distal metaphyseal tibia fractures. Methods: Patients who had internal fixation of comminuted tibia shaft or distal metaphyseal tibia fracture and a concurrent fibular fracture treated with intramedullary Steinman pin fixation were included in this study. Patients' demographic data and fracture patterns were analyzed retrospectively. Postoperative X-rays were used for fracture union evaluation and alignment analysis. Results: Nine males and one female were included in the present study. Tibia fractures were classified as four OTA42 and as six OTA43, including one type I, two type II, one type IIIA, and three type IIIB open fractures. Intramedullary nail and locking plate were used as definitive fixation in four and six cases, respectively. Complications required additional surgeries including wound debridement for one patient, bone graft for three patients, and revision surgery from a broken plate to an intramedullary nail for one patient. A total of 14 fibula fractures were identified in ten patients due to four segmental fractures. Eight were Weber type C, one was Weber type B, and five were midshaft fractures. The mean duration of fibula fracture healing according to radiographs was 6.9 months. Conclusions: This study suggests that intramedullary Steinmann pin fixation for concurrent fibula fracture is a critical procedure when dealing with comminuted shaft or distal metaphyseal tibia fractures.
Keywords: Intramedullary fixation, comminuted tibia fracture, distal metaphyseal tibia fracture, concurrent fibula fracture
|How to cite this article:|
Lee PY, Chen CM, Tseng HS, Yang JJ. Outcomes of intramedullary steinmann pin fixation for concurrent fibula fracture in comminuted tibia shaft or distal metaphyseal tibia fractures. J Med Sci 2021;41:173-8
|How to cite this URL:|
Lee PY, Chen CM, Tseng HS, Yang JJ. Outcomes of intramedullary steinmann pin fixation for concurrent fibula fracture in comminuted tibia shaft or distal metaphyseal tibia fractures. J Med Sci [serial online] 2021 [cited 2021 Oct 25];41:173-8. Available from: https://www.jmedscindmc.com/text.asp?2021/41/4/173/305053
| Introduction|| |
Fracture of the tibia shaft accounts for 17% of lower extremity fractures, with concurrent fibula fracture in about 78% of these cases., Most tibia shaft fractures are managed with internal fixation. However, surgical indications for concurrent fibula fractures are controversial because various fracture locations may lead to different effects on the stability of ankle and knee joints. Midshaft fibula fractures can be managed conservatively. However, proximal fibula fractures associated with ligamentous injuries and distal fibula fractures in the lateral malleolus region, which tend to result in ankle joint instability, should be fixed.,
Surgical intervention of tibia fractures is often associated with surgical wound problems because of the thin soft-tissue envelope. To avoid these complications, closed or minimally invasive reduction should always be attempted, but this may be hindered in comminuted shaft fractures due to the inherent difficulty in repositioning the cortex to achieve good fracture apposition. Intramedullary fixation for distal metaphyseal tibia fracture may lead to malalignment because the metaphysis does not afford a snug, endosteal fit for an intramedullary nail. However, restoration of fibula alignment and lateral column length can facilitate fracture reduction in such cases, especially with comminuted tibia shaft or distal metaphyseal tibia fractures.
Most commonly, the preferred surgical treatment for fibula fractures is open reduction and internal fixation with plate and screws. However, lateral plating can lead to complications such as wound breakdown and infection due to the poor skin envelope surrounding the distal fibula. Furthermore, patients often complain about prominent hardware that requires subsequent removal. Intramedullary pin fixation can be performed either percutaneously or minimal invasively to minimize potential soft-tissue problems. Therefore, when concerned about soft-tissue complications, our surgical team uses Steinman pins as an intramedullary device for fibula fixation.
The aim of this study was to demonstrate our experience with treating concurrent fibula fractures with intramedullary Steinmann pins in comminuted tibia shaft or distal metaphyseal tibia fractures.
| Methods|| |
Study design and population
This retrospective study was conducted at the Orthopaedics Department of Tri-Service General Hospital and included patients who received internal fixation of comminuted tibia shaft or distal metaphyseal tibia fractures with concurrent fibular fracture treated with intramedullary Steinman pin fixation from September 2016 to November 2019. The study protocol was approved by the Institutional Review Board of our hospital. Patients who had internal fixation of comminuted tibia shaft or distal metaphyseal tibia fracture and a concurrent fibular fracture treated with intramedullary Steinman pin fixation were included in this study. The study was approved by Tri-Service General Hospital, National Defense Medical Center. No.A202005102 & Date: June /19/ 2020.
Demographics and clinical characteristics
Patients' demographic data and fracture patterns were analyzed retrospectively. Open fractures were classified according to the Gustilo classification. Tibia fractures locations were classified according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification. Fibula fracture locations were classified as midshaft or Danis-Weber ankle fracture classification type A, B, or C.
Surgical technique and postoperative management
The surgical technique of intramedullary fixation for fibula fracture is described as follows. A small longitudinal incision about 0.5 cm was made on the tip of the lateral malleolus. The lower extremity alignment was maintained by manual traction. A 2.0 or 2.4 mm Steinman pin was inserted into the tip of the lateral malleolus. Fibula alignment was checked under C-arm fluoroscopy. The pin was advanced proximally to the fracture site under the guidance of fluoroscopy by adjusting the pin direction and modulating the reduction position. If the closed reduction and pin insertion were difficult, a small assistant incision was made for easier reduction and pin insertion. After fixation, the caudal end of the pin was bent, shortened, and buried under the skin. Next, intramedullary nailing or plate fixation was carried out for the closed tibial fracture. Type I, II, and IIIA open fractures were treated with emergent wound debridement and then, as with closed fractures, by one-stage surgery with tibia and fibula fixation. Type IIIB fractures were treated with staged surgeries under open fracture principals, including series of wound debridement, fibula intramedullary pin fixation, temporary tibia external fixation, and definitive free flap coverage. Final tibia fixation was performed after soft-tissue swelling subsided. A short-leg splint with the ankle joint in a neutral position was applied for 4 weeks. Then, ankle joint motion exercises were encouraged and toe-touch weight-bearing was allowed. Partial weight-bearing was allowed when early callus formation was observed radiographically. To prevent skin irritation, all fibula Steinman pins were removed after the bony union of the fracture site.
Postoperative radiographic analysis
During the follow-up, X-rays were taken for fracture union evaluation at standard time intervals of 2 weeks, 4 weeks, 6 weeks, 2 months, 3 months, 6 months, and 12 months. Malreduction was defined as the coronal or sagittal plane deviation > 5° on immediate postoperative radiographs. Loss of acceptable reduction was defined as more than 5° of coronal angulation or more than 10° of sagittal angulation.
| Results|| |
All ten patients (mean age: 46.8; nine males and one female) were included in the present study. Detailed data of all cases and summary are shown in [Table 1] and [Table 2]. Tibia fractures were classified as four OTA42 and as six OTA43, including one type I, two type II, one type IIIA, and three type IIIB open fractures. All three patients with type IIIB open fractures received staged surgeries, including wound debridement, fibula intramedullary fixation, temporary external tibia fixation, free flap wound coverage, and definitive tibia internal fixation. Intramedullary nail and locking plate were used as definitive fixation in four and six cases, respectively [representative cases are shown in [Figure 1] and [Figure 2]]. One patient had a superficial wound infection and healed after wound debridement and antibiotic treatment. Postoperative radiographs of 1 tibia fracture were defined as malreduction. Tibia nonunion, which required additional bone graft surgery, occurred in one patient with Gustilo type II and three patients with type IIIB open fractures. One patient with Gustilo type IIIB fracture experienced plate breakage with loss of reduction and received revision surgery of intramedullary nail fixation. Bony union was achieved over all tibia fractures with a mean duration of 18.2 months (range, 7.5–33 months). A total of 14 fibula fractures were identified in 10 patients due to 4 segmental fractures. Eight were Weber type C, one was Weber type B, and five were midshaft fractures. No complications were observed in fibula fracture cases. The mean duration of fibula fracture healing according to radiographs was 6.9 months (range, 4–16 months). The fibula union rate after 12 months is 90%.
|Figure 1: (a) Preoperative films showing a comminuted tibia shaft fracture with a concurrent fibula fracture. (b) Postoperative films showing tibia fixation with an intramedullary nail and fibula fixation with an intramedullary Steinman pin. (c) Final films showing bone union of both tibia and fibula fractures|
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|Figure 2: (a) Preoperative films showing a comminuted distal metaphyseal tibia fracture with concurrent segmental fibula fractures. (b) Postoperative films showing temporary external tibia fixation and fibula fixation with an intramedullary Steinman pin. (c) Postoperative films showing definitive tibia fixation with a locking plate. (d) Final films showing partial union of tibia fracture and complete union of fibula fractures|
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| Discussion|| |
In the present study, the treatment of concurrent fibula fractures with intramedullary Steinmann pin in comminuted tibia shaft or distal metaphyseal tibia fractures in ten patients resulted in anatomical reduction and fracture union within an average of 6.9 months in all fibula fractures, including seven open fractures. Additional tibia surgeries were needed in some patients due to complications, including wound debridement in one patient, bone graft in three patients, and implant revision from plate to intramedullary nail in one patient. The mean union time for tibial fracture was 18.2 months. All complications occurred in patients with open fractures with accompanying compromised soft-tissue and serious bone loss.
The weight-bearing function of the fibula accounts for 6.4% of weight distribution. In addition to its axial load-sharing role, the bony structure of the fibula also contributes to the maintenance of ankle stability. Clinical and cadaveric studies of fibula resection have indicated that 8 cm of residual distal fibular length is needed to maintain ankle stability., Besides the fibular bony structure, the ligaments attached to the fibula, including lateral collateral and syndesmotic ligaments, are crucial stabilizers of the ankle joint. Therefore, the restoration of good fibular alignment is able to increase ankle joint stability.
To date, the necessity of adjunctive fibular fixation remains debatable. Prior fibula fixation restores lateral column length and facilitates tibia fracture reduction, especially for comminuted or distal metaphyseal tibia fractures. Furthermore, the restored stability of the lateral column can decrease the incidence of malunion by lower-limb alignment maintenance, especially when using intramedullary fixation for distal tibia fixation., The results of biomechanical studies suggest that adding supplemental fibular fracture fixation to intramedullary nail fixation of distal tibia fractures increases construct stability and may decrease the risk of valgus malunion., In contrast, recent studies involving intramedullary nail and minimally invasive percutaneous plate osteosynthesis have demonstrated good functional outcomes without significant malalignment regardless of fibular fixation, suggesting that adequate stabilization of tibia fractures is possible while avoiding the morbidity of soft-tissue disruption and infection risk commonly associated with standard ORIF approaches., In the literature, the predominance of retrospective studies demonstrates that the lack of prospective and randomized clinical trials hinders the ability to reach consensus on the ideal approach for these fractures.
Far fewer reports of intramedullary fixation have been published compared with reports of plates for fibula fractures. The more frequently used intramedullary implants include rush pin, Knowles pin, and headless compression screws.,, The advantage of intramedullary fixation includes the biomechanical properties of load sharing and soft-tissue protection due to less stripping. However, the most concerning aspect is less stability compared to that associated with plates, which is essentially due to the lack of proper implants for fibula fixation, although several new anatomic devices are in development. Insufficient evidence exists in the current literature for changing the practice from the plating of unstable distal fibular fractures to intramedullary fixation. However, we think that the construct strength of intramedullary Steinman pins is sufficient for fibula fixation because of the low weight distribution. None of our cases were found to have loss of reduction over fibula fracture. Although Steinman pin removal is usually needed to prevent skin irritation, it can be performed with a small incision under local anesthesia. In the present study, most cases were open fractures, which already have high complication rates due to soft-tissue compromise. Given such conditions, intramedullary fixation avoids unnecessary soft-tissue dissection and the resulting fracture nonunion that may occur after plating. Segmental fibula fractures also impede the application of plates because of the lack of implants with adequate length to cover both fracture sites for construct mechanical strength.
The obvious limitations of this study include its retrospective nature and the lack of a control group for comparison. A further prospective study of intramedullary Steinmann pins for treating concurrent fibula fractures in comminuted tibia shaft or distal metaphyseal tibia fractures compared to treatment with plates or a conservative method should be conducted to verify the effects of intramedullary fibula fixation.
| Conclusions|| |
By weighting the substantial structural stability acquired and the advantage of minimal soft-tissue dissection, the results of this study suggest that intramedullary Steinmann pin fixation for concurrent fibula fracture is a critical procedure when dealing with comminuted shaft or distal metaphyseal tibia fractures.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]