Distal Locking of Tibial Nails

The indications for intramedullary nailing have expanded to include most tibial shaft fractures. Nail design has improved since their first introduction, but distal locking remains a difficult part of the procedure, resulting in radiation exposure to the patient and the surgeon and increased operation time. To address these issues, we describe an alternative surgical technique using a newly designed distal targeting device that consists of a proximally mounted aiming arm, and we report the preliminary data from its use in all tibial shaft fractures amenable to surgery for a 2–year period. Sixty-three tibial shaft fractures were treated with this method. The mean duration of the distal locking was 6.5 minutes, and in all successful cases, radiation exposure for distal locking was two shots (one shot before targeting and another for the confirmation of proper screw insertion). Radiation exposure was on average 0.85 seconds (range, 0.4–1.2 seconds) and 1.4 mGy (range, 0.8–1.9 mGy). There were no major intraoperative complications related to the technique. The method has certain advantages and can reduce radiation exposure and operation time. Nonetheless, familiarity with the instrumentation is a prerequisite for accurate distal locking.Level of Evidence: Level IV Therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

[1]  J. Koebke,et al.  Antegrade femoral nailing: an anatomical determination of the correct entry point. , 2002, Injury.

[2]  C. Krettek,et al.  In vitro and in vivo radiomorphometric analyses of distal screw hole position of the solid tibial nail following insertion. , 1997, Clinical biomechanics.

[3]  C Krettek,et al.  Novel Computer-Assisted Fluoroscopy System for Intraoperative Guidance: Feasibility Study for Distal Locking of Femoral Nails , 2001, Journal of orthopaedic trauma.

[4]  D. Pennig,et al.  Intramedullary locked nailing of femur and tibia: insertion of distal locking screws without image intensifier. , 1997, Injury.

[5]  Ivan Zuna,et al.  Fluoroscopic guidance versus surgical navigation for distal locking of intramedullary implants. A prospective, controlled clinical study. , 2004, Injury.

[6]  R. Gross,et al.  A simplified technique of distal femoral screw insertion for the Grosse-Kempf interlocking nail. , 1988, Clinical orthopaedics and related research.

[7]  S. Kelley,et al.  A Simple Technique for Insertion of Distal Screws into Interlocking Nails , 1995, Journal of orthopaedic trauma.

[8]  F. Kummer,et al.  Intramedullary Nailing of the Lower Extremity: Biomechanics and Biology , 2007, The Journal of the American Academy of Orthopaedic Surgeons.

[9]  Virginia Tsapaki,et al.  Estimation of radiation doses to patients and surgeons from various fluoroscopically guided orthopaedic surgeries. , 2007, Radiation protection dosimetry.

[10]  C Krettek,et al.  A new technique for the distal locking of solid AO unreamed tibial nails. , 1997, Journal of orthopaedic trauma.

[11]  L. Nokes,et al.  Literature review of current techniques for the insertion of distal screws into intramedullary locking nails. , 2006, Injury.

[12]  J. D. Goodall.  An image intensifier laser guidance system for the distal locking of an intramedullary nail. , 1991, Injury.

[13]  C Krettek,et al.  The deformation of small diameter solid tibial nails with unreamed intramedullary insertion. , 1997, Journal of biomechanics.

[14]  Chi-Chuan Wu,et al.  Biomechanical analysis of the mechanism of interlocking nail failure , 2004, Archives of Orthopaedic and Trauma Surgery.

[15]  Z. Gugala,et al.  Tibial intramedullary nail distal interlocking screw placement: comparison of the free-hand versus distally-based targeting device techniques. , 2001, Injury.

[16]  G. Grobler,et al.  Inserting the distal screws in a locked femoral nail. , 1991, The Journal of bone and joint surgery. British volume.

[17]  B. Browner,et al.  Radiation exposure to the surgeon during closed interlocking intramedullary nailing. , 1987, The Journal of bone and joint surgery. American volume.

[18]  S Tyropoulos,et al.  A new distal targeting device for closed interlocking nailing. , 2001, Injury.

[19]  D Pardiwala,et al.  The AO distal locking aiming device: an evaluation of efficacy and learning curve. , 2001, Injury.

[20]  N. Goddard,et al.  A simple jig to ease the insertion of distal screws in intramedullary locking nails. , 1994, Injury.

[21]  G. Anastopoulos,et al.  Distal Locking with Mechanical Jig (Author’s Own Technique) , 2006 .

[22]  M. Davis,et al.  Radiation exposure and associated risks to operating-room personnel during use of fluoroscopic guidance for selected orthopaedic surgical procedures. , 1983, The Journal of bone and joint surgery. American volume.

[23]  S A Riley,et al.  Exposure of the orthopaedic surgeon to radiation. , 1994, The Journal of bone and joint surgery. American volume.

[24]  D. Pennig.  An improved screw design for locked intramedullary nailing. , 1997, Injury.

[25]  C Krettek,et al.  Deformation of femoral nails with intramedullary insertion , 1998, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.