Retrograde Tibial Nailing: a minimally invasive and biomechanically superior alternative to angle-stable plate osteosynthesis in distal tibia fractures

Abstract

BackgroundCurrently, antegrade intramedullary nailing and minimally invasive plate osteosynthesis (MIPO) represent the main surgical alternatives in distal tibial fractures. However, neither choice is optimal for all bony and soft tissue injuries. The Retrograde Tibial Nail (RTN) is a small-caliber prototype implant, which is introduced through a 2-cm-long incision at the tip of the medial malleolus with stab incisions sufficient for interlocking. During this project, we investigated the feasibility of retrograde tibial nailing in a cadaver model and conducted biomechanical testing.MethodsAnatomical implantations of the RTN were carried out in AO/OTA 43 A1-3 fracture types in three cadaveric lower limbs. Biomechanical testing was conducted in an AO/OTA 43 A3 fracture model for extra-axial compression, torsion, and destructive extra-axial compression. Sixteen composite tibiae were used to compare the RTN against an angle-stable plate osteosynthesis (Medial Distal Tibial Plate, Synthes®). Statistical analysis was performed by Student's t test.ResultsRetrograde intramedullary nailing is feasible in simple fracture types by closed manual reduction and percutaneous reduction forceps, while in highly comminuted fractures, the use of a large distractor can aid the reduction. Biomechanical testing shows a statistically superior stability (p < 0.001) of the RTN during non-destructive axial loading and torsion. Destructive extra-axial compression testing resulted in failure of all plate constructs, while all RTN specimens survived the maximal load of 1,200 N.ConclusionsThe prototype retrograde tibial nail meets the requirements of maximum soft tissue protection by a minimally invasive surgical approach with the ability of secure fracture fixation by multiple locking options. Retrograde tibial nailing with the RTN is a promising concept in the treatment of distal tibia fractures.

Complications after surgical management of distal lower leg fractures

“…A staged procedure is preferable. Further development of intramedullary nailing systems and insertion points (retrograde nailing) keep this method of fracture fixation attractive even in the fixation of very distal lower leg fractures [6]. Smaller skin incisions, easier postoperative care and early weight bearing are the main advantages of intramedullary nailing devices.…”

“…Surgical treatment of distal tibiofibular fractures with intramedullary nailing (IMN) is the preferred method of repair [5], even in very distal fractures [6]. Some studies have even popularized intramedullary nailing in open fractures [5, 7, 8].…”

Novel Retrograde Tibial Intramedullary Nailing for Distal Tibial Fractures

“…First, In terms of biomechanics, the RTN has better resistance to rotation and similar axial stability compared with the ATN ( 15 ). Second, compared with the distal medial tibial plate, the RTN has both better rotation and axial stability ( 16 ). It is well known that good biomechanical stability is one of the necessary conditions for fracture healing, and all patients in this group successfully achieved the fracture healing, which also reflects the good stability of the RTN.…”

Retrograde tibial nailing of far distal tibia fractures: a biomechanical evaluation of double- versus triple-distal interlocking

“…Several attempts have been made in the past, dating back to Küntscher and Maatz in 1945 [ 1 ] as well as Hofmann in the late 1990s [ 2 , 3 ]. However, until the introduction of the Distal Tibial Nail (DTN; Mizuho ® , Japan) in 2017, no dedicated surgical implant was available [ 4 ]. Regarding this implant, three distal locking options are at 13, 19.5 and 26 mm from the nail end; the distal locking screws converge in the a.p.…”

“…It covers a wide range of fractures in the distal tibia [ 5 ], preserves local soft tissues and vascularisation, and offers superior biomechanical performance to plating [ 5 ] and equivalent biomechanical performance to other nailing options [ 6 ]. Following promising pre-clinical biomechanical testing results, the DTN was introduced into clinical practice in Japan in 2017 [ 4 – 6 ].

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