Treatment of Distal Tibial Fractures with Distal Tibial Nail (DTN)
Distal tibial fractures are a common type of lower-extremity fracture. Traditional treatments, such as locking plates and antegrade intramedullary nailing, each have drawbacks. Locking plates may lead to postoperative infection or soft tissue necrosis, prolonging recovery. Antegrade intramedullary nailing, although minimally invasive, may damage the knee joint, cause knee pain, and carries risks of inadequate fixation or malalignment, which can compromise rehabilitation outcomes.
Today, we introduce a novel treatment option—the Distal Tibial Nail (DTN). Its unique retrograde intramedullary design offers a new perspective for managing distal tibial fractures.
01 Surgical Procedure
The patient is placed in the supine position. Displaced fractures require manual reduction to an acceptable position; if necessary, bone forceps may be used to assist reduction before DTN insertion. If a fibular fracture is present, realigning the fibula can help achieve tibial reduction. Fibular shaft fractures may be stabilized with an intramedullary nail. For fibular fractures around the ankle, anatomical reduction and fixation of the fibula should be performed first to avoid improper tibial reduction. In open fractures that have already been treated with external fixation, the DTN can be inserted while maintaining the fixator in place to aid reduction.
Figure 1 a: Photograph of the DTN and targeting device. b: Radiograph showing DTN treatment of a distal tibial fracture.
A 2–3 cm longitudinal incision is made at the tip of the medial malleolus, exposing the superficial layer of the deltoid ligament. A guidewire is inserted at the tip of the medial malleolus or slightly medial to it (Figure 2a), keeping 4–5 mm from the joint surface. Lateral views confirm the guidewire is placed through the intercondylar groove (Figure 2b), taking care to avoid injury to the tibialis posterior muscle. The superficial deltoid ligament is dissected, and the medullary canal is reamed up to the metaphysis using a reamer (Figure 2c). Cancellous bone near the proximal medial cortex is removed to facilitate insertion of the nail (Figure 2d). A trial nail is inserted to confirm the appropriate DTN size (Figure 2e). Avoid forceful hammering or excessive torsion of the DTN to prevent iatrogenic medial malleolar fracture. The insertion depth of the DTN is adjusted to ensure that distal locking screws do not enter the tibiotalar joint or the fracture zone. Both distal and proximal interlocking screws are used for fixation.
Figure 2 Operative steps.
02 Postoperative Rehabilitation Protocol
Weight-bearing on the foot is allowed immediately postoperatively, along with ankle range-of-motion exercises.
At 4–6 weeks postoperatively, the affected limb remains non-weight-bearing. Full weight-bearing is initiated at 8–12 weeks, with monitoring of callus formation and pain.
03 Results
The study enrolled and followed 10 patients (Table 1). At 3 months postoperatively, 7 fractures had healed; all fractures healed within 6 months. One case each of varus deformity and recurvatum deformity was observed. No loss of reduction occurred. There were no infections, implant-related complications, or iatrogenic injuries (Table 2).
Table 1 Clinical characteristics of enrolled patients.
Table 2 Radiographic outcomes and complications in this study compared with literature review.
Case report:
A 69-year-old male patient with a transverse tibial fracture and fibular fracture (Figure 3a). Soft tissue crush injury was present (Figure 3b). The fibular fracture was fixed with an intramedullary nail, and the tibial fracture with a DTN (Figure 4a). The tibial procedure required only six small incisions, with no soft tissue complications (Figure 3c). Healing was achieved at one year postoperatively (Figure 4b).
Figure 3 a: Distal tibial transverse fracture and simple distal fibular fracture. b: Crush injury around the leg with poor soft tissue condition. c: Postoperative photograph.
Figure 4 a: Postoperative radiograph. b: Radiograph at 1 year postoperatively, showing healing. c: Proper orientation for insertion of three distal locking screws.
04 Discussion
(I) Indications for DTN
This study included AO type 43-A and C1 fractures, with C2 fractures also considered. DTN lengths were 7 mm, 8 mm, and 8 mm (note: these likely refer to nail diameters or lengths; the text states "lengths" but values are small—please verify original units; presumably diameters in mm). Different nail sizes determine the position of proximal locking screws. Fractures with the fracture line within 2–9 cm from the distal tibial articular surface are suitable for DTN fixation, and indications may be extended to AO type 42 fractures.
(II) Biomechanical stability of DTN
Retrograde intramedullary nails exhibit greater stiffness under axial loading and rotational stability compared to medial locking plates and antegrade nails. Greenfield et al. conducted biomechanical comparative experiments; when using two distal interlocking screws, the DTN showed compressive stiffness 60–70% of that with three screws, and torsional stiffness 90%; under compressive and torsional loading, interfragmentary motion was minimal. Three patients did not heal within 3 months postoperatively, possibly related to soft tissue injury, canal reaming, fracture line location, and osteoporosis. Since the DTN is available in only three sizes, the canal-filling ratio does not increase with reaming, and distal fixation relies on only three screws, which may not provide sufficient stability. For patients with canal enlargement, osteoporosis, or very distal fractures, early postoperative weight-bearing should be cautious. To ensure stable fixation, we recommend inserting two proximal screws and three distal screws.
(III) Advantages of DTN
Compared with locking plates, intramedullary nails cause less soft tissue trauma, making them particularly suitable for elderly patients and those with severe soft tissue injury after high-energy trauma. In this study, only six small incisions were used for DTN insertion, with no soft tissue complications. The procedure does not require knee flexion, reducing the risk of loss of reduction, and is applicable in patients with limited knee flexion (e.g., knee degenerative disease or after ipsilateral knee arthroplasty).
(IV) Disadvantages of DTN
Surgical risks include injury to the tibialis posterior muscle and medial malleolar fracture. If medial malleolar fracture occurs, it can be managed with tension band wiring, plating, or external fixation.
Additionally, screw penetration into the fibular notch should be avoided. The weight of the targeting device may cause posterior rotation of the DTN, requiring adjustment of the second screw so that it is directed toward the fibula (Figure 4c).
(V) Clinical outcomes
Nonunion and malalignment rates for antegrade intramedullary nailing are 0–25% and 8.3–50%, respectively; for locking plates, 0–17% and 0–17%. In this study, all fractures healed, and only 20% had deformity >5°, with results comparable to those of locking plates and antegrade nails.
Regarding soft tissue infection, superficial infection rates for antegrade nailing and locking plates are 0–8.3% and 0–23%, respectively; deep infection rates are 0–23% and 0–8.3%. This study observed no soft tissue complications, outperforming both methods.
AOFAS Ankle-Hindfoot Scale scores: for type A fractures, antegrade nailing scored 86–88, locking plates 84–88, and type C fractures scored 73. In this study, the mean score was 92.6, showing comparable effectiveness. EQ-5D-5L scores: locking plate treatment ranged 0.62–0.76, while this study scored 0.876, higher than the former. SAFE-Q scores: foot and ankle patients ranged 67–75, while this study scored 83–91.7, indicating good treatment outcomes (Table 3).
Table 3 Clinical scores in this study compared with literature review.
In summary, the DTN offers advantages over locking plates and antegrade intramedullary nails and can be considered an effective treatment option for distal tibial fractures.
References
Yamakawa Y, Uehara T, Shigemoto K, et al. Preliminary results of stabilization of far distal tibia fractures with the distal tibial nail: a prospective, multicenter case series study[J]. Injury, 2024: 111634.