Evaluation of clinical and functional outcome of open reduction/closed reduction with intra medullary interlocking nailing and `Poller' blocking screws in tibial metaphyseal fractures

Abstract

INTRODUCTION: Interlocking nailing of tibial fractures are most desirable because these are load sharing devices in compare to load bearing plate osteosynthesis implants. Biological fixation of the fracture is possible in the method of nailing without opening the fracture site, further it is possible to spare the extra osseous blood supply and we can avoid extensive soft tissue dissection. Nailing of metaphyseal fractures with short proximal or distal fragment is associated with an increase in malalignment particularly in coronal plane, so there is always a chance for mal union, rarely non union and need for secondary procedures to achieve union. The cause has been attributed to both displacing muscular forces and medullary canal anatomical factors. As there is always a mismatch between the diameters of the nail and the medullary canal, with no nail-cortex contact, the nail may translate coronally or sagittaly particularly in proximal tibial fractures. Due to this there is a increased stress on the locking screws to maintain fracture alignment after surgery, which further leads to periprosthetic fractures and implant failure. Various techniques have been recommended to improve nailing procedures for the metaphyseal fractures these are, “poller” blocking screws, temporary unicortical plating, different nail designs with different proximal bends in case of proximal third fractures and fibular plating in case of distal third fractures. Poller screws are named after a traffic guiding device used in European countries to guide the traffic on the roads. They are used for the following three purposes: a) Achievement of the fracture alignment, by using screw as a reduction tool. b) Improvement of the stability of the bone – implant Construct by reducing the medullary canal width. c) Maintenance the fracture alignment till union with poller screws in situ. AIM OF THE STUDY: To evaluate the Clinical and Functional Outcome of Closed Reduction / Open Reduction and Internal fixation with Intramedullary Inter Locking Nailing and “POLLER” BLOCKING SCREWS in Tibial Metaphyseal Fractures. MATERIALS AND METHODS: This is a prospective study of 20 cases of tibial metaphyseal fractures treated with open reduction/closed reduction with statically locked intra medullary nailing an ‘ poller screws’ between August 2010 and September 2012 at Govt. Rajaji Hospital, Madurai Medical College, Maduari. Patients Inclusion criteria: •Adult patients more than 20 years of age. •Either proximal or distal metaphyseal fractures. •Unstable, comminuted metaphyseal fractures of tibia with varying soft tissue injuries. •Segmental fractures with involvement of metaphysis. Exclusion criteria: •Adolescent patients <20 yrs of age. •Very minimally (or) undisplaced fractures. •Tibial metaphyseal fractures involving the articular surface. •Associated with previous anatomic deformities. •Fractures with wound at the nail entry site. •Compound Gr II, Gr III A-C. RESULTS: Multiple measurements are made on the same individual at different point of times. In line with this, the variables in our study were the angle at the fracture site measured within the same subjects at different point of times. Because few extreme values of variables of normal distribution should not mislead the interpretation of analysis, 95 % upper and lower confidence limits were preferred over range to express the variables.Karlstorm-Olerud score which was used to asses the functional outcome is an independent measurement, not influenced by other co-morbid conditions and associated injuries. CONCLUSION: We conclude that the surgical management of, open reduction/closed eduction with intra medullary interlocking nailing and poller screws in tibial metaphyseal fractures. •Is effective in achieving the fracture alignment with poller screw acting as a reduction tool •Gives improved stability of the bone – implant construct, with the poller screw functionally reducing the medullary width. •Maintains the fracture alignment till union, preventing loss of initial reduction with poller blocking screw in situ