Most orthopaedic surgeons do not regard tibial shaft fractures as a management dilemma. You just nail them, they nearly always heal, & you discharge them.
But just how good are the results from the patients’ perspective? For that, you need long-term outcome studies.
And what would be the likely outcome if they were treated another way? A patient has a right to discuss alternative treatments & their expected outcomes. We have a duty to provide accurate answers.
In this post, I’m going to outline some of the tibial shaft studies that explain why we do what we (generally) do, and what the outcomes are like.
Bone et al, ‘Displaced Isolated Fractures of the Tibial Shaft Treated with Either a Cast or Intramedullary Nailing. An Outcome Analysis of Matched Pairs of Patients’. JBJS: September 1997 – Volume 79 – Issue 9 – p 1336-41
n=99. Assessment = Iowa Knee Evaluation & Ankle Evaluation Rating System, Medical Outcomes Study Short Form-36 Health Survey.
Time to union was shorter in patients managed with IM nailing than those who had been managed with a cast (mean, 18 -v-26 weeks; p = 0.02). Non-union occurred in one IMN patient (2 per cent) & 5 cast patients (10%). No infections in either group. Removal of IMN was performed in 26 patients. 25 IMN patients & 25 cast patients were followed for a mean of 4.4 years. The IMN patients had mean scores of 96 points (range, 68 to 100 points) and 97 points (range, 74 to 100 points) for the knee and the ankle, respectively, compared with 89 points (range, 62 to 100 points) and 84 points (range, 62 to 100 points) for cast patients (p < 0.05). Administration of the SF-36 to the 25 matched pairs of patients yielded scores that were significantly better after IMN than after treatment with a cast (a mean of 85 points [range, 27 to 99 points] compared with a mean of 74 points [range, 20 to 97 points]; p < 0.05).
Keating, J. F.; Orfaly, R.*; O’Brien, P. J, 1997. ‘Knee pain after tibial nailing’. Journal of Orthopaedic Trauma: January 1997 – Volume 11 – Issue 1 – p 10-13.
n= 110. Follow-up 12-58 months, mean 32 months.
63/110 (57%) patients had developed anterior knee pain. There was no correlation between nail protrusion and knee pain. Insertion of the nail through the patella tendon was associated with a higher incidence of knee pain compared to the paratendon site of nail insertion (77% and 50% respectively). Of patients with knee pain, 80% (49/61) required nail removal. At a mean duration of 16 months following nail removal, pain was completely relieved in 22 patients and partially relieved in 17. In the remaining 10 patients, there was no improvement.
The authors recommended a parapatellar tendon incision for nail insertion, and nail removal for those patients with a painful knee.
LeFaivre et al, 2008. ‘Long-Term Follow-up of Tibial Shaft Fractures Treated With Intramedullary Nailing’. Journal of Orthopaedic Trauma: September 2008 – Volume 22 – Issue 8 – p 525-529.
doi: 10.1097/BOT.0b013e318180e646
50 patients out of 250 eligible patients agreed to take part (potential source of bias). Median follow-up 14 years (12 – 17).
Assessments: SF-36 and Short Musculoskeletal Functional Assessments, and an injury-specific questionnaire focusing on knee pain and symptoms of venous insufficiency. A subgroup of patients were evaluated radiographically and by physical examination.
The authors found:
‘The mean normalized SF-36 scores (physical composite score-PCS 48.9, mental composite score-MCS 51.8) and the mean normalized Short Musculoskeletal Functional Assessment scores (50.7) (bothersome index, functional index) were not statistically different (P > 0.05) from reference population norms. Of the questionnaire group (n = 56), only 15 (26.7%) denied knee pain with any activity whereas 41 patients (73.2%) had at least moderate knee pain. With respect to swelling, 19 (33.9%) reported asymmetrical swelling affecting the injured limb. However, of the 33 physically examined patients, only 6 (18.2%) had objective evidence of venous stasis. Knee range of motion was equivalent to the unaffected side in all but two patients (93.9%) whereas 14 (42.4%) had a restricted range of motion of the ankle. Nine patients (27.3%) had persistent quadriceps atrophy, and the same rate was observed for calf atrophy. Twenty-five patients (75.8%) had no tenderness to anterior knee palpation. Of the 31 radiographically examined patients, 11 patients (35.4%) showed evidence of arthritis despite the absence of radiographic malalignment. Five patients (16.1%) had at least mild osteoarthristis of at least one knee compartment, 5 (16.1%) had at least mild osteoarthristis of the tibio-talar joint, and 1 (3.2%) had osteoarthristis of both, despite the absence of malunion. Self-reported knee pain was not correlated with the presence of a tibial nail or radiographic nail prominence. Similarly, knee tenderness on examination was not correlated with these factors.’
In the long-term, patients’ function is comparable to population norms, but objective and subjective evaluation shows persistent sequelae. Some of these sequelae – post-traumatic arthritis & post-thrombotic syndrome – could deteriorate in future years.
Vaisto et al, 2008. ‘Anterior Knee Pain After Intramedullary Nailing of Fractures of the Tibial Shaft: An Eight-Year Follow-Up of a Prospective, Randomized Study Comparing Two Different Nail-Insertion Techniques’. The Journal of Trauma: Injury, Infection, and Critical Care: June 2008 – Volume 64 – Issue 6 – p 1511-1516
doi: 10.1097/TA.0b013e318031cd27
n=50, randomised to either trans-tendinous or paratendinous nailing. Assessment: At initial & 8-year follow-up, visual analog scales to report level of anterior knee pain & the impairment caused by the pain. The scales of Lysholm and Gillquist; Tegner et al.; the Iowa knee scoring system, and simple functional tests were used to quantitate the functional results. Isokinetic thigh-muscle strength was also measured.
‘Four (29%) of the 14 patients treated with transtendinous nailing reported anterior knee pain at the 8-year follow-up evaluation. The number was the same for patients treated with paratendinous nailing. The Lysholm, Tegner, and Iowa knee scoring systems, the muscle-strength measurements, and the functional tests showed no significant differences between the two groups.‘
They felt that in many cases the anterior knee pain eventually disappeared.
Maxwell Courtney et al, 2015, ‘Functional Knee Outcomes in Infrapatellar and Suprapatellar Tibial Nailing: Does Approach Matter?’ The American Journal of Orthopaedics, E513-E516.
n=45. 24 infrapatellar nails; 21 suprapatellar nails. Assessment : Oxford Knee Score. Retrospective.
Mean OKS (maximum, 48 points) was 40.1 for the infrapatellar group and
36.7 for the suprapatellar group (P = .293). Compared with the infrapatellar approach, suprapatellar nailing improved radiographic reduction in the sagittal plane (2.90° vs 4.58°; P = .044) and required less operative fluoroscopy time (81 vs 122 s; P = .003).
The authors found no difference in OKS between the infrapatellar and suprapatellar approaches. They thought that the suprapatellar approach was a safe alternative.
MacDonald et al, ‘Tibial nailing using a suprapatellar rather than an infrapatellar approach significantly reduces anterior knee pain postoperatively: a multicentre clinical trial’. Bone Joint J, 2019;101-B:1138–1143.
n=53. RCT. Assessment: Aberdeen Weightbearing Test – Knee (AWT-K) score and a visual analogue scale (VAS) score for pain. The AWT-K is an objective patient-reported outcome measure that uses weight transmitted through the knee when kneeling as a surrogate for anterior knee pain.
Their conclusion: ‘The suprapatellar surgical approach for antegrade tibial nailing is associated with less anterior knee pain postoperatively compared with the infrapatellar approach.’
Gaston et al, 1999, ‘Fractures of the tibia. Can their outcome be predicted?’J Bone Joint Surg [Br] 1999;81-B:71-6.
n=100/130 tibial fractures treated with IMN. Classified by clinical & radiological methods: AO, Tscherne, Gustilo & Anderson, Winquist & Hansen.
Assessments: time to full weight-bearing, time to union, nonunion, malunion, deep infection.
In addition, the time taken to return to a number of routine daily activities was recorded, including the ability to maintain an awkward posture, kneel for a prolonged period, stoop or crawl, walk for a prolonged period, climb stairs or a slope, walk over difficult ground, jump, climb a ladder and run. These outcome criteria have been validated by Watson, and have been used by the authors for a number of years. The time taken to restart work, sports training and normal sporting activities was also noted.
None of the classifications was strongly predictive of outcome. The Tscherne classification was the most predictive.
Coles & Gross, ‘Closed Tibial Shaft Fractures: Management & Treatment Complications. A review of the prospective literature. CJS, Vol. 43, No. 4, August 2000 256-262.
n=895 from 13 studies (data pooled). Treatment arms: cast, plate, unreamed IMN, reamed IMN.
Although definitions varied, the combined incidence of delayed and nonunion was lower with operative treatment (2.6% with plate
fixation, 8.0% with reamed nailing and 16.7% with unreamed nailing) than with closed treatment (17.2%).
The incidence of malunion was similarly lower with operative treatment (0% with plate fixation, 3.2% with reamed nailing and 11.8% with unreamed nailing) than with closed treatment (31.7%).
Superficial infection was most common with plate fixation (9.0%) compared with 2.9% for reamed nailing, 0.5% for unreamed nailing and 0% for closed treatment. The incidence of osteomyelitis was similar for all groups. Rates of reoperation ranged from 4.7% to 23.1%.
Skoog et al, ‘One-year outcome after tibial shaft fractures: Results of a prospective fracture registry’. J Orthopaedic Trauma (2001) Vol15, No 3, pp210-215.
n=64 tibial fracture patients. Assessments: Clinical outcome, functional results, SF-36, Olerud-Molander Ankle Score, Visual Analogue Scale.
43 (67%) were treated with an IMN. SF-36 diminished, compared to pre-injury, at 4 & 12 months post-injury. At 12 months, 44% had not regained full function of the injured leg, though all but 2 had returned to pre-injury working status.
Dogra, Ruiz, Marsh. ‘Late Outcome of Isolated Tibial Fractures Treated by Intramedullary Nailing: The Correlation between Disease-Specific and Generic Outcome Measures.’ Journal of Orthopaedic Trauma: April 2002 – Volume 16 – Issue 4 – p 245-249.
n=83. Retrospective. Minimum 3 years follow-up. Mean 57 months. assessment: Iowa Knee and Ankle Scores, visual analogue pain scores for fracture site and knee and ankle joints, and the Short Form 36 health status questionnaire.
64 (77.1%) fractures united after the first procedure. 29 (34.9%) patients had pain around the knee at rest, 59 (71.1%) had difficulty in kneeling, and 13 (15.7%) were still experiencing some pain at their fracture site; 69% of patients had excellent results based on the Iowa scores as well as the SF-36 scores. Pain at the knee correlated with low Physical Component Summary and Mental Component Summary scores, and fracture site pain correlated with only low Physical Component Summary score. There was a significant correlation between the disease-specific scores and the SF-36 scores, and only patients with an excellent Iowa grade had “normal” SF-36 scores.
Authors’ conclusions:
After tibial nailing, mild deficits registered by Iowa scores are associated with a significant disability and unhappiness as registered by the SF-36. According to the patient-oriented outcomes tool, 31% of late results are “unsatisfactory.”
Ferguson et al, ‘ Outcomes of Isolated Tibial Shaft Fractures Treated At Level 1 Trauma Centres’. Injury, Int J Care Injured (2008) 39, 187-195.
n=60 isolated tibial shaft fractures. 1 year outcome assessed with SF-12 (also at baseline); work sub-scale of the Sickness Impact Profile; and Numerical Rating for Pain.
Full weight-bearing achieved at median 14 weeks. Median time to radiological union 35 weeks. No clear changes in mental health. Physical health scores significantly reduced. 47% reported work-related disability and 40% experienced persistent pain 1 year post-injury.
Foster et al, 2012.’The treatment of complex tibial shaft fractures by the Ilizarov method’.Volume 94-B, Issue 12, December 1, 2012, Pages 1678-1683. https://doi.org/10.1302/0301-620X.94B12.29266
n=40 fractures, 19 of which were open fractures. Age 19-81, mean 43.
36/40 healed with the first frame; the rest with the second. There were no deep infections, malunions or amputations. 23% suffered pinsite infections of mild degree which required oral antibiotics.
In addition, they found: ‘Clinical scores were available for 32 of the 40 patients at a median of 55 months (mean 62, (26to 99)) post-injury, with ‘good’ Olerud and Molander ankle scores(median 80, mean 75, (10 to 100)), ‘excellent’ Lysholm knee scores(median 97, mean 88, (29 to 100)), a median Tegner activity scoreof 4 (mean 4, (0 to 9)) (comparable to ‘moderately heavy labour/ cycling and jogging’) and Short Form-12 scores that exceeded the mean of the population as a whole (median physical component score55 (mean 51, (20 to 64)), median mental component score 57 (mean53, (21 to 62))’.
Erin-Madsen et al, ‘Knee pain and associated complications after intramedullary nailing of tibial shaft fracture’. Dan Med J
2019;66(8):A5554
n & take-up rate: 233/351. Assessment: KOOS scale. Follow-up 1.7-6.7 years.
The authors commented:
‘Knee pain, swelling and stiffness, restrictions in quality of life and limitations in sports remain common complications after operation with the insertion of an intra-medullary nail after tibia shaft fracture. When compared to a reference population, younger patients and women in general reported more difficulties. After a follow-up period of up to nearly seven years, the primary limitations were reported on ”Sports and Recreation” and ”Quality of Life”. Among the 18-34-year-olds in the ”Sport and Recreation” group, 76.9% of the women and 75% of the men indicated that they had either experienced ”severe” or ”extreme” difficulty while kneeling in the past week’.
Summary.
Cast treatment of displaced tibial shaft fractures used to be exacting for both patient & doctor. The results often left much to be desired, with nonunion, malunion & stiffness not uncommon. It is not now commonly used in adults unless the fracture is undisplaced, because other methods produce superior results.
Plate fixation seemed to offer a way forward in the 60s & 70s; it works well in relatively low energy injuries (such as recreational ski injuries). However, in the comminuted fractures and soft tissue injuries of high energy road traffic collisions, plating too often leads to the disaster of wound breakdown, infection, & non-union. Refracture because of screw holes in the diaphysis was also a significant problem.
Locked IMN nailing of the tibial shaft was introduced into practice in the 80s. Early experience indicated a high rate of union & satisfactory outcomes (Cross A, Montgomery RJ: The treatment of tibial shaft fractures by the locking medullary nail system. J Bone Joint Surg Br; 69: 489,1987). Over the years, this technique has come to predominate in the treatment of tibial shaft fractures.
For those wishing to avoid a nail, or for those whose canal is blocked, deformed or too narrow, external fixation with a monolateral or ring fixator offers a reasonable alternative. Adherence to a recognised pin site regime is vital if a miserable series of pinsite infections & pin loosening is to be avoided. Circular frame treatment is demanding & inconvenient for patient & surgeon, but it is safe and effective when performed by enthusiasts.
Whether or not a fracture heals satisfactorily depends not only on the extent of damage and the surgeon’s skill; it also depends on the patient’s health & habits. Smoking, drinking alcohol, non-steroidal anti-inflammatories and prolonged opiate use can adversely affect callus (healing bone formation).
A patient who suffers a tibial shaft fracture will typically recover well enough to go back to their previous job and function in society. However if we ask patients about sport & recreational activities in sufficient detail, and let patients assess their own recovery, we see that often it is not a complete recovery.
We discharge them from the clinic once the bone is healed, but that is far from the end of their journey. If we are to improve outcomes further, we will have to listen more to the long term outcomes and devise better techniques & rehab pathways to prevent the residual problems. We are not doing badly, but there is certainly scope for improvement.