Rush Nail in the Management of Distal One-third Fibular Fracture in Both Bone Fractured Legs: A Clinical Study

Vol 32 | Issue 2 | July – Sep 2017 | page:32-36 | Rizwan Khan, Javed Jameel, Sandeep Kumar, Ammar Aslam, Gaurav Chahal, Shishir Rastogi.


Authors: Rizwan Khan [1], Javed Jameel [1], Sandeep Kumar [1], Ammar Aslam [1], Gaurav Chahal [1], Shishir Rastogi [1].

[1] Hamdard Institute of Medical Sciences and Research, New Delhi, India.

Address of Correspondence

Javed Jameel,
Hamdard Institute of Medical Sciences and Research,
New Delhi, India.
E-mail: drjavedjameel@gmail.com


Abstract

Background: Aim of this study is to evaluate the results of percutaneous rush pin fixation in distal third fibula in both bone fractured legs.
Materials and Methods: Forty patients were treated from emergency and outpatient department, having closed fracture of the distal third fibula in both bone fractured legs.
Results: Out of 40 patients, 35 patients underwent union in 3-4 months. Touch-down weight bearing was started on 2nd post-operative day. Complications were found in five patients who had delayed union in three and soft-tissue infection at the nail entry point in two patients.
Conclusions: Fixation using rush nail in distal third fibular fracture is a safe and effective method of surgery that could be performed in patients with compromised soft-tissue condition and showed sufficient stability after fixation.
Key words: Fibular fracture, percutaneous, rush pin, both bone fractures.


Introduction

Fractures of distal tibia are almost always accompanied with a fibular fracture the fixation of which is always a matter of debate1. Plate fixation is the most frequent technique used for stabilization of fibula but percutaneous techniques (pins, screw fixation) have also been proposed2. Plate fixation of these fractures is challenging owing to wound infection, mechanical failures & symptoms related to metalwork which are more frequent in elderly and patients of diabetes & neuropathy. Considering these complication rush nail seems to be a better alternative as it offers a stable fixation with minimal surgical exposure and less prominent metal work.
Materials and Method: 40 Patients Were Selected Which Had closed fractures of both bone leg with fibula fracture at distal one third. A written informed consent was obtained from all the patients; they were explained about treatment plan, cost of operation, and hospital stay after surgery, and complications of anesthesia. They were followed-up after surgery, were clinically and radiologically assessed for fracture healing, joint movements, and implant failure.In majority of the patients close rush nailing of fibula was performed within 24-48 hrs after the injury. Fracture of leg were evaluated using plain radiographs in anteroposterior (A-P) and lateral. The fractures were classified using the AO/OTA classification systems.
Inclusion criteria: Age 18-60 yrs, all both bone leg fracture with distal one third fibula
Exclusion criteria: Age <18, compound grade 111 b fibula fracture, pathological fracture
Surgical technique
The patient was placed in supine position with a bump underneath the ipsilateral hip to prevent the usual external rotation of the limb and to give access to the lateral side of the ankle. The entire limb was prepared and draped. The starting point for the rush nail was the distal tip of the fibula. A small (approximately 2 cm) longitudinal incision was made approximately 2-3 cm distal to the tip of the fibula; it should be distal enough to allow the drill bit to drill in line with the fibular shaft. A sharp elevator cleared the soft tissue at the tip of the fibula to create a “landing zone” for the drill bit. With the help of an image intensifier, a 3.5 mm bit was used to drill an opening hole in the distal fibula. It is essential to drill in line with the diaphysis of the fibula on both A-P and lateral images to facilitate passage of the rush nail. After the opening hole was made, a long 2.5 mm drill bit was used to “ream” the distal fibula to approximately 5-6 cm. A soft-tissue sleeve for the 2.5 mm drill bit was inserted into the previously drilled starting hole. A 2.4 mm rush nail was locked securely onto the T-handle chuck. Tip of the nail was bend 10 degree approx that helped in reduction and the passing of nail .The nail was then placed into the starting hole distally and advanced proximally with controlled mallet strikes on the chuck. Rush nail can be controlled with a T-handle chuck, “choking up” on the nail and resetting the chuck farther back as the nail is advanced into the fibula. There should be minimal resistance with nail insertion, and the T-handle should be rotated in 45± motions while the mallet is used. At the fracture site, the nail was advanced across the fracture and into the proximal fragment medullary canal. A closed reduction technique, such as axial traction or blunt manipulation of the fracture fragments, can be used to pass the rush nail. The nail was advanced 5-10 cm into the fibular medullary canal in the proximal fragment. The distal end of the bend nail was then impacted into the lateral malleolus. The wound was then irrigated and closed with nylon sutures. For tibia conventional intermedullary interlocking nailing done. Rehabilitation such as touch down weight bearing was started on 2 nd postoperative day and sutures were removed on 14 th postoperative day. These patients were assessed clinically and radiologically for union timing at 6 months following surgery. 

Results
5 patients out of 40 complained postoperative ankle pain, which was spontaneously resolved in 2 weeks. There were 3, delayed unions which were treated by platelet rich plasma and bone marrow injection. In our study two patients had soft tissue infection at the point of entry of nail that was managed by antibiotics. No rotational instability was seen in any patients postoperatively. Patients were followed-up at 1,2, 3 and 6 months till one year  respectively. No cases of degenerative arthritis were noted in patients. The patients were evaluated by American foot and ankle score in which  35 patients had score above 90 and 5 were above 80, (Table 1).

Discussion

Distal tibial fractures occur in about 38% of all tibial fractures and in about 78% of these fractures there is a concomitant distal fibula fracture3 . There are different modalities of fixation of fibular fracture viz plate osteosynthesis2, cannulated cancellous screw and Rush nail1. However there is no clear cut consensus in literature on the fixation of fibular fracture in  combined distal tibia and fibula both bone leg , there exists a debate among surgeons as to whether or not fibular fixation is required as an adjuvant to IM nailing of tibia3. Plate osteosynthesis for fractures of the distal tibia is often associated with delayed healing, infection, and hardware problems4,5.In our study 3 cases of delayed healing, 1 case of infection and 1 case of hardware problem was seen. In cases of fibular fixation in fracture both bone lower leg there is less varus or valgus angulation, less rotational deformity and faster union time6. In our study foot and ankle score for  35 patient was above 90, remaining 5 also had good AOFAS SCORE above 80. For distal tibia fractures that also have a fibula fracture, plating of the fibula fracture before nailing of the tibia can help provide alignment and length3. This is particularly useful for simple fibular fracture patterns and very distal tibial fracture patterns. When nailing for a combined distal tibia and fibula fracture, the distal end of nail must anchor in the physeal scar adjacent to the subchondral bone to reduce toggling of narrower nail inside a wider metaphyseal medullary canal which will prevent the nail to deviate mediolaterally and prevent malunion. Care should be taken to reduce the fibula as malreduction of the fibula will prevent accurate reduction of the tibia. After the fibula is plated, care should be taken to make sure the tibia is not malaligned in varus as the fibular plating will keep the tibia out to length laterally, but will typically not prevent varus collapse. Study by Asloum et al concluded that Dilemma of the fibular fixation: Fibula fixation is controversial. If the fibular fixation is fixed with plating, it prevents collapse of the comminuted metaphyseal area or gap, resulting in nonunion or malunion with deformity of tibia. If the fibular fracture is not fixed, the ankle mortise may not be congruous, because if not fixed lateral malleolus may get displaced. If the fibula is fixed, bone grafting is mandatory if there is comminuted or gap/bone loss2. Lambert demonstrated that the fibula has weight bearing function, carrying 1/6 of the load applied to the knee joint7. Prior studies have suggested fibular fixation may influence outcomes of distal tibial fractures favourably but significant complications have also been reported with this adjunctive stabilisation. High-energy fractures of the distal tibia are associated with a high incidence of soft tissue trauma compromising the soft tissue envelope. So ORIF of the fibula has also shown an increased rate of wound complications7. In addition, the incidence of fibular nonunions was 9% with fibular fixation possibly from further devascularisation on open surgical approach in contrast to zero without fibular fixation8. There are very few studies on intramedullary fibular nailing. The main criticism of this system is that it is not rigid enough. However, the notion of an interlocking nailing system cannot be compared to simple percutaneous nailing systems. The series evaluating the latter report the benefits of the percutaneous approach, but functional results vary9. The idea of nailing was first introduced in 1999–2000 with the ANK® nail. Kara et al. and Kabukcuoglu et al. used this nailing system for lateral malleolar fractures associated with syndesmotic injury, and they reported good results and no complications2. The fibula nail provides a relatively easy technique for treating displaced fracture both bone leg involving distal one third fibula fractures. We found a high success rate with its use as depicted by foot and ankle score in our study. AOFAS was more than 90 in 35 patient & more than 80 in remaining 5 patient which is good standard. This technique affords the opportunity to provide fixation through a minimal approach with a limited incision, which decreases the chances of wound infection1. Further, the intra-medullary fixation eliminates the need for hardware removal from the lateral malleolus due to prominent metal work as compared with conventional technique of plating . In a study by Singh et al 25 patients  underwent intramedullary interlocking nailing for fractures of the distal third of the tibia and  rush nail for fractures of the distal third of the fibula1.The mean time to union was 16 weeks. Sixteen patients underwent dynamisation at 12 weeks leading to union of fracture . Two patients had angular malalignment within acceptable limits, but none had rotational malalignment. No patient had shortening, hardware breakdown, or deep-seated infection, only 1 patient had superficial infection of lateral malleolar incision but it was managed well with oral antibiotics and dressing1. In our case 40 patient went for rush nail fibula . All 40 patient fracture united with no rotational malalignment seen. 35 patients had excellent AOFAS score of more than 90. 5 patients had AOFAS good score more than 80 out of which 3 had delayed union  & 2 patient had nail insertion infection. But in none patient there was non union. Alignment was acceptable in all. Distal fractures are prone to malalignment because the metaphysis is much wider than the diameter of the nail and care must be taken to avoid malunion as this may lead to a worse functional outcome3. The keys to avoiding malalignment distally are ensuring the guidewire is placed centrally on both the AP and lateral images (the ―center-center position‖) and keeping the fracture well aligned during reaming and nail insertion. In a study by Khuntia et al \the role of fibular fixation in the treatment of distal third tibial fractures was evaluated10. 40 patients with concomitant fractures of tibia and ipsilateral fibula at distal third level were included in this study during a 48 month period. Patients were randomized in two groups: patients with fibular fixation (group I) and without fibular fixation (group II). The patients were followed up for at least 1 year follow up postoperatively. Johner And Wruh’s Criteria was used for evaluation of functional outcome. Excellent and good results were seen in majority of the patients (85%) in group I as compared to group II (65%). Infection was seen in one patient in group I and two in group II with Gustillo-Anderson II injuries. Majority of patients of both groups union occurred at 16 to 17 weeks of post operative with Average time of union came out to be 16.6 weeks in non-fixing group and 17.85 weeks in fixing group. Most patients about 60% of non-fixing group showed some variety of deformity of valgus/varus and antiversion/recurvation in post union x-ray and some were in unacceptable range. 20% patients of fixation group showed deformity but in acceptable range. We observed unacceptable shortening in 3 patients of non fibula fixation group and acceptable shortening in 5 patients of fibula fixation group. There were 2 patients having non union one in each group. Four patients were infected with two from each group include both superficial and deep infection Knee movement was full in 90% of cases. In three patients there was restriction of 10°-15° of flexion with no extension lag. Ankle movement was full in 80% cases. In 3 out of 8 patients; ankle movement was restricted by 25% in dorsiflexion Johner And Wruh’s Criteria was used for evaluation of functional outcome. Excellent and good results were seen in majority of the patients (85%) in fixation group as compared to non fixation group about 65% and very less number in fair and poor result in fixation group as compared to non-fixation group10. Potential advantages of fibular fixation include mechanical stability, assisting in reduction & restoring the length and alignment of the tibia. While such a construct cannot control rotation, it can preserve length as well as prevent varus and valgus displacement. In our study, all the fibular fractures were fixed with rush rods and did not see any rotational instability. Thus we conclude that in extraarticular fractures of distal tibia with concurrent distal fibular fractures it is advisable to fix the fibular fractures with an intramedullary rush nail rather than a plate for the reasons cited above along with intramedullary interlocking nail for tibia. Usage  of  rush  nails  for  fixation  lower  fibula  fractures  is  having  added advantage  of  small  skin  incision  hence  less  chances  of  local  infection, dynamization  was  more  effectively  achieved,  less  chances  of  rotational instability  in  presence  of  distal  locking  of  tibia,  and  more  important  in present era is reduction of cost of surgery over all1.

Clinical relevance
The fibula nail is probably the ideal choice for fixing distal one third fibula fracture in both bone leg especially with overlying skin conditions, or other immunocompromised  states such as diabetes in which there are higher infection rates with traditional plating techniques. We found a low complication rate and little difficulty with its use intra-operatively. Intramedullary nailing is a percutaneous mini-invasive technique that provides stable fixation and reduces the risk of wound complications. The main limitation is in the treatment of comminuted fractures


References

1. Singh N, Anjum R, Chib M S. A prospective study on intramedullary nailing for both tibia and fibula in distal both bone leg fractures. International Journal of Advanced Research 2015:3;47-49
2. Asloum Y, Bedin B, Roger T, Charissoux Jl, Arnaud J P, Mabit C. Internal Fixation Of The Fibula In Ankle Fractures. A Prospective, Randomized And Comparative Study: plating versus nailing. Orthop traumatol surg res 2014;100:255-9
3. Bucholz R, Heckman J, Court-Brown C. Rockwood and Green’s fractures in adults. 8th ed
4. Tanna DD. Interlocking nailing. 2nd ed. New Delhi: Jaypee Publishers; 2004.
5. Olerud S, Karlstrom G. Tibial fractures treated by AO compression osteosynthesis. Experiences from a five year material. Acta Orthop Scand Suppl 1972;140:1–104.
6. Krishna C, Mondal J. Fracture fixation of both bone lower third leg using minimally invasive plate osteosynthesis technique – is fixation of fibula necessary.International Surgery Journal. 2016 May;3(2):589-594
7. Lambert KL (1971) The weight-bearing function of the fibula.A strain gauge study. J Bone Joint Surg Am 53:507–513
8. Williams TM, Marsh JL, Nepola JV et al (1998) External fixation of tibial plafond fractures: is routine plating of the fibula necessary? J Orthop Trauma 12:16–20
9. Morin PM, Reindl R, Harvey EJ, Beckman L, Steffen T. Fibular fixation as an adjuvant to tibial intramedullary nailing in the treatment of combined distal third tibia and fibula fractures: a biomechanical investigation. Can J Surg 2008;51:45–50
10. Khuntia S,Sahu A, Mall P, Mishra A, Panda S, Sahu S, Mohapatra S, Dash A, Biswas M. Managements of Distal Third Both Bone Leg Fractures By Tibia Interlocking – is Fibular Fixation Mandatory? IOSR Journal of Dental and Medical Sciences 2017;16:36-39


How to Cite this Article: Khan R, Jameel J, Kumar S, Aslam A, Chahal G, Rastogi S. Rush Nail in the Management of Distal One-third Fibular Fracture in Both Bone Fractured Legs: A Clinical Study. Journal of Bone and Joint Diseases. Jul-Sep 2017;32(2):32-36.

 


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