A Study of the Functional Outcome of Distal Both Bone Leg Fractures Treated with Tip Locking Interlocking Nailing and Fibular Plating

Background: Intramedullary nail fixation remains the treatment of choice of unstable and displaced tibial shaft fractures in adults. The goals of treatment are to achieve osseous union and to restore length, alignment and rotation of the fractured tibia. The implant offers appropriate biomechanics fracture stabilisation and acts as a load sharing device allowing early postoperative mobilisation. Recent advances in nail design and reduction techniques have expanded the indications for intramedullary nail fixation to include distal third tibial fractures. Materials and Methods: A prospective observational study based on 100 cases of distal both bone leg fractures admitted and treated surgically in Orthopaedic wards of Government Medical College Trivandrum for a period of 1yr during the study period. Data was collected using structured pro forma, questionnaire and functional outcome analysed based on American Orthopaedic Foot and Ankle Score. The axis of the leg was studied using Paley and Tets worth method on post-operative X-rays. Results: The study included 101 patients with distal both bone leg fractures who fulfilled the criteria. The age of the patients ranged from 18 years to 67 years, the largest age group was 21 years to 30 years 34.9% of patients. Males (77%) were predominant in our study. Most had right sided involvement (62%). The study had about 63% closed fractures. Patients were treated based on hospital protocol and were followed up at 6 weeks 12 weeks and at 6 months for clinical and radiological evaluation. Assessment of functional outcome was done using American Orthopaedic Foot and Ankle Society score after attaining weight bearing. The mean AOFAS score was 77.15 (Range of 45 to 100). The mean score in males was 77.35 and in females was slightly lower at 76.47. Closed fractures showed better mean score of 84.68 while open fractures had a mean score of 64.13. The average time taken to partial weight bearing was 7 weeks (range of 3 weeks to 16 weeks). The average time taken to full weight bearing was 11 weeks (range of 6 weeks to 20 weeks). The average time taken to return to work was 16 weeks (range of 8 weeks to 25 weeks). Out of the 101 patients, 12 patients have changed their job or have not returned to their job since they were not able to continue in their previous jobs due to their injury. The rest of the patients were able to return to their previous jobs without any difficulties. The radiological parameters revealed that 5 of the 101 patients had a varus deformity in the immediate postop X- ray. The average varus angle according to the Paley and Tets worth method was found to be 5.5 degrees (Range of 0-11 degrees).6 patients had fixation in valgus with the average valgus angle being 8.5 degrees (Range 0-17 degrees). The X- rays revealed 4 patients with more than 10 degrees of recurvatum angle by Paley and Tets worth method in lateral Xrays. All four had higher recurvatum angles than the immediate post op period indicating a loss of reduction or malalignment. The average recurvatum angle in the final follow up x-rays were 4.56 degrees (Range of 0 to 16.5 degrees). In the follow up examination where the minimal follow up period was 6 months, wound healing was 96%. 1 patient was excluded because of wound infection. He sustained an open fracture (Gustilo 3B) for which he underwent intramedullary nailing with fibular fixation. During followup his wound infection did not resolve with antibiotics. Hence 3 months post-op he underwent nail exit and ortho fix fixation. 4 patients underwent additional procedures. Mostly for their soft tissue cover in the form of split thickness skin grafting except for one patient who underwent bone grafting in addition to skin grafting for a metaphyseal bone loss 1 month after the intramedullary nailing. Conclusion: From our study we conclude that intramedullary nailing of distal both leg fractures along with fibular plating allowed early mobilization of knee joint with excellent functional outcome. The AOFAS performed well in assessing the functional outcome. Functional outcome mainly depended upon the type of injury with closed fractures showing significantly better scores than open fractures. Functional outcome was not related to age or sex of the patient. Complications like malalignment are present with nailing of distal third tibial fractures even though it is a universally accepted modality of treatment.