Biomechanical comparison of distal locking screws for distal tibia fracture intramedullary nailing
ABSTRACT
Background: Newer generation intramedullary (IM) tibial nails provide several distal interlocking screw options. The objectives were to determine: 1) if the new oblique interlocking option provides superior stability, 2) which screw orientation/ configuration is the most biomechanically stable, and 3) if three distal interlocking screws provide better stability. Methods: A preliminary experiment was performed in torsion, compression, and bending tests with four different screw configurations: (I) one medial-to-lateral and one oblique, (II) two me-dial-to-lateral, (III) one medial-to-lateral and one anterior-to-posterior, and (IV) one medial-to-lateral, one anterior-to-posterior and one oblique in simu-lated distal metaphyseal fracture tibiae. Twenty- four Synthes EXPERT tibial IM nails were used for six specimens of each screw configuration. Parts I and II, tibial IM nails were locked with 5.0 mm in-terlocking screws into simulated distal tibiae (PVC and composite analogue tibia). Part III, the two most stable configurations were tested using five pairs of simulated cadaveric distal tibiae metaphy-seal fractures. Results: Significant differences were attributable to distal screw orientation for intrame- dullary nailing of distal tibia fractures. Configura-tions II and IV were found to be more stable than the other two configurations. No significant differ-ence was detected in construct stability in all modes of testing between Configurations II and IV. Dis-cussion: Configuration I did not provide superior stability for the distal tibia fracture fixation. Con-figurations II and IV provided equivalent stability. When choosing IM fixation for treatment of distal tibia metaphyseal fractures two medial-to-lateral screws provide the necessary stability for satisfac-tory fixation. Clinical Relevance: This study indi-cated an option for operative treatment of distal metaphyseal tibia fracture fixation where preserva-tion of soft tissue and rigid stabilization are needed.
Background: Newer generation intramedullary (IM) tibial nails provide several distal interlocking screw options. The objectives were to determine: 1) if the new oblique interlocking option provides superior stability, 2) which screw orientation/ configuration is the most biomechanically stable, and 3) if three distal interlocking screws provide better stability. Methods: A preliminary experiment was performed in torsion, compression, and bending tests with four different screw configurations: (I) one medial-to-lateral and one oblique, (II) two me-dial-to-lateral, (III) one medial-to-lateral and one anterior-to-posterior, and (IV) one medial-to-lateral, one anterior-to-posterior and one oblique in simu-lated distal metaphyseal fracture tibiae. Twenty- four Synthes EXPERT tibial IM nails were used for six specimens of each screw configuration. Parts I and II, tibial IM nails were locked with 5.0 mm in-terlocking screws into simulated distal tibiae (PVC and composite analogue tibia). Part III, the two most stable configurations were tested using five pairs of simulated cadaveric distal tibiae metaphy-seal fractures. Results: Significant differences were attributable to distal screw orientation for intrame- dullary nailing of distal tibia fractures. Configura-tions II and IV were found to be more stable than the other two configurations. No significant differ-ence was detected in construct stability in all modes of testing between Configurations II and IV. Dis-cussion: Configuration I did not provide superior stability for the distal tibia fracture fixation. Con-figurations II and IV provided equivalent stability. When choosing IM fixation for treatment of distal tibia metaphyseal fractures two medial-to-lateral screws provide the necessary stability for satisfac-tory fixation. Clinical Relevance: This study indi-cated an option for operative treatment of distal metaphyseal tibia fracture fixation where preserva-tion of soft tissue and rigid stabilization are needed.
Cite this paper
nullLucas, B. , Chong, A. , Buhr, B. , Jones, T. and Wooley, P. (2011) Biomechanical comparison of distal locking screws for distal tibia fracture intramedullary nailing. Journal of Biomedical Science and Engineering, 4, 235-241. doi: 10.4236/jbise.2011.44032.
nullLucas, B. , Chong, A. , Buhr, B. , Jones, T. and Wooley, P. (2011) Biomechanical comparison of distal locking screws for distal tibia fracture intramedullary nailing. Journal of Biomedical Science and Engineering, 4, 235-241. doi: 10.4236/jbise.2011.44032.
References
[1] Dogra, A.S., Ruiz, A.L., Thompson, N.S. and Nolan, P.C. (2000) Dia-metaphyseal distal tibial fractures-treatment with a shortened intramedullary nail: A review of 15 cases. Injury, 31, 799-804. [2] Gorczyca, J.T., McKale, J., Pugh, K. and Pienkowski, D. (2002) Modified tibial nails for treating distal tibia fractures. Journal of Orthopaedic Trauma, 16, 18-22. doi:10.1097/00005131-200201000-00004 [3] Fan, C.Y., Chiang, C.C., Chuang, T.Y., Chiu, F.Y. and Chen, T.H. (2005) Interlocking nails for displaced metaphyseal fractures of the distal tibia. Injury, 36, 669-674. doi:10.1016/j.injury.2004.10.018 [4] Alho, A., Ekeland, A., Stromsoe, K., Folleras, G. and Thoresen, B.O. (1990) Locked intramedullary nailing for displaced tibial shaft fractures. The Journal of Bone and Joint Surgery. British Volume, 72, 805-809. [5] Blachut, P.A., O’Brien, P.J., Meek, R.N. and Broekhuyse, H.M. (1997) Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. The Journal of Bone and Joint Surgery. American Volume, 79, 640-646. [6] Bone, L.B. and Johnson, K.D. (1986) Treatment of tibial fractures by reaming and intramedullary nailing. The Journal of Bone and Joint Surgery. American Volume, 68, 877-887. [7] Court-Brown, C.M., Christie, J. and McQueen, M.M. (1990) Closed intramedullary tibial nailing. Its use in closed and type I open fractures. The Journal of Bone and Joint Surgery. British Volume, 72, 605-611. [8] Dehne, E., Metz, C.W., Deffer, P.A. and Hall, R.M. (1961) Nonoperative treatment of the fractured tibia by immediate weight bearing. Journal of Trauma, 1, 514-535. [9] Sarmiento, A., Gersten, L.M., Sobol, P.A., Shankwiler, J.A. and Vangsness, C.T. (1989) Tibial shaft fractures treated with functional braces. Experience with 780 fractures. The Journal of bone and joint surgery. British volume, 71, 602-609. [10] Im, G.I. and Tae, S.K. (2005) Distal metaphyseal fractures of tibia: A prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation. Journal of Trauma, 59, 1219-1223 (Discussion 1223). doi:10.1097/01.ta.0000188936.79798.4e [11] Nork, S.E., Schwartz, A.K., Agel, J., Holt, S.K., Schrick, J.L. and Winquist, R.A. (2005) Intramedullary nailing of distal metaphyseal tibial fractures. The Journal of Bone and Joint Surgery. American Volume, 87, 1213-1221. doi:10.2106/JBJS.C.01135 [12] Andrew, H.S., Christopher, G.F. and Paul, T. III (2003) Treatment of closed tibial fractures. The Journal of Bone and Joint Surgery. American Volume, 85, 352-368. [13] Mosheiff, R., Safran, O., Segal, D. and Liebergall, M. (1999) The unreamed tibial nail in the treatment of distal metaphyseal fractures. Injury, 30, 83-90. doi:10.1016/S0020-1383(98)00213-7 [14] Laflamme, G.Y., Heimlich, D., Stephen, D., Kreder, H.J. and Whyne, C.M. (2003) Proximal tibial fracture stability with intramedullary nail fixation using oblique interlocking screws. Journal of Orthopaedic Trauma, 17, 496-502. doi:10.1097/00005131-200308000-00004 [15] Chen, A.L., Tejwani, N.C., Joseph, T.N., Kummer, F.J. and Koval, K.J. (2001-2002) The effect of distal screw orientation on the intrinsic stability of a tibial intramedullary nail. Bulletin (Hospital for Joint Diseases (New York, N.Y.)), 60, 80-83. [16] Roberts, C.S., King, D., Wang, M., Seligson, D. and Voor, M.J. (1999) Should distal interlocking of tibial nails be performed from a medial or a lateral direction? anatomical and biomechanical considerations. Journal of Orthopaedic Trauma, 13, 27-32. doi:10.1097/00005131-199901000-00007 [17] Kneifel, T. and Buckley, R. (1996) A comparison of one versus two distal locking screws in tibial fractures treated with unreamed tibial nails: A prospective randomized clinical trial. Injury, 27, 271-273. doi:10.1016/0020-1383(95)00116-6 [18] George, C.J., Lindsey, R.W., Noble, P.C., Alexander, J.W. and Kamaric, E. (1998) Optimal location of a single distal interlocking screw in intramedullary nailing of distal third femoral shaft fractures. Journal of Orthopaedic Trauma, 12, 267-272. doi:10.1097/00005131-199805000-00009 [19] Gollwitzer, H., Karampour, K., Hauschild, M., Diehl, P., Busch, R. and Mittelmeier, W. (2004) Biomechanical investigation of the primary stability of intramedullary compression nails in the proximal tibia: Experimental study using interlocking screws in cryopreserved human tibias. Journal of Orthopaedic Science, 9, 22-28. [20] Heidemann, W., Gerlach, K.L., Gr?bel, K.H. and K?llner, H.G. (1998) Influence of different pilot hole sizes on torque measurements and pullout analysis of osteosynthesis screws. Journal of Cranio-maxillo-facial Surgery, 26, 50-55. doi:10.1016/S1010-5182(98)80035-8 [21] Heidemann, W., Gerlach, K.L., Gr?bel, K.H. and K?llner, H.G. (1998) Drill Free Screws: a new form of osteosynthesis screw. Journal of Cranio-maxillo-facial Surgery, 26, 163-168. doi:10.1016/S1010-5182(98)80007-3 [22] Osterkamp, L.K. (1995) Current perspective on assessment of human body proportions of relevance to amputees. Journal of the American Dietetic Association, 95, 215-218. doi:10.1016/S0002-8223(95)00050-X
[1] Dogra, A.S., Ruiz, A.L., Thompson, N.S. and Nolan, P.C. (2000) Dia-metaphyseal distal tibial fractures-treatment with a shortened intramedullary nail: A review of 15 cases. Injury, 31, 799-804. [2] Gorczyca, J.T., McKale, J., Pugh, K. and Pienkowski, D. (2002) Modified tibial nails for treating distal tibia fractures. Journal of Orthopaedic Trauma, 16, 18-22. doi:10.1097/00005131-200201000-00004 [3] Fan, C.Y., Chiang, C.C., Chuang, T.Y., Chiu, F.Y. and Chen, T.H. (2005) Interlocking nails for displaced metaphyseal fractures of the distal tibia. Injury, 36, 669-674. doi:10.1016/j.injury.2004.10.018 [4] Alho, A., Ekeland, A., Stromsoe, K., Folleras, G. and Thoresen, B.O. (1990) Locked intramedullary nailing for displaced tibial shaft fractures. The Journal of Bone and Joint Surgery. British Volume, 72, 805-809. [5] Blachut, P.A., O’Brien, P.J., Meek, R.N. and Broekhuyse, H.M. (1997) Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial shaft. A prospective, randomized study. The Journal of Bone and Joint Surgery. American Volume, 79, 640-646. [6] Bone, L.B. and Johnson, K.D. (1986) Treatment of tibial fractures by reaming and intramedullary nailing. The Journal of Bone and Joint Surgery. American Volume, 68, 877-887. [7] Court-Brown, C.M., Christie, J. and McQueen, M.M. (1990) Closed intramedullary tibial nailing. Its use in closed and type I open fractures. The Journal of Bone and Joint Surgery. British Volume, 72, 605-611. [8] Dehne, E., Metz, C.W., Deffer, P.A. and Hall, R.M. (1961) Nonoperative treatment of the fractured tibia by immediate weight bearing. Journal of Trauma, 1, 514-535. [9] Sarmiento, A., Gersten, L.M., Sobol, P.A., Shankwiler, J.A. and Vangsness, C.T. (1989) Tibial shaft fractures treated with functional braces. Experience with 780 fractures. The Journal of bone and joint surgery. British volume, 71, 602-609. [10] Im, G.I. and Tae, S.K. (2005) Distal metaphyseal fractures of tibia: A prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation. Journal of Trauma, 59, 1219-1223 (Discussion 1223). doi:10.1097/01.ta.0000188936.79798.4e [11] Nork, S.E., Schwartz, A.K., Agel, J., Holt, S.K., Schrick, J.L. and Winquist, R.A. (2005) Intramedullary nailing of distal metaphyseal tibial fractures. The Journal of Bone and Joint Surgery. American Volume, 87, 1213-1221. doi:10.2106/JBJS.C.01135 [12] Andrew, H.S., Christopher, G.F. and Paul, T. III (2003) Treatment of closed tibial fractures. The Journal of Bone and Joint Surgery. American Volume, 85, 352-368. [13] Mosheiff, R., Safran, O., Segal, D. and Liebergall, M. (1999) The unreamed tibial nail in the treatment of distal metaphyseal fractures. Injury, 30, 83-90. doi:10.1016/S0020-1383(98)00213-7 [14] Laflamme, G.Y., Heimlich, D., Stephen, D., Kreder, H.J. and Whyne, C.M. (2003) Proximal tibial fracture stability with intramedullary nail fixation using oblique interlocking screws. Journal of Orthopaedic Trauma, 17, 496-502. doi:10.1097/00005131-200308000-00004 [15] Chen, A.L., Tejwani, N.C., Joseph, T.N., Kummer, F.J. and Koval, K.J. (2001-2002) The effect of distal screw orientation on the intrinsic stability of a tibial intramedullary nail. Bulletin (Hospital for Joint Diseases (New York, N.Y.)), 60, 80-83. [16] Roberts, C.S., King, D., Wang, M., Seligson, D. and Voor, M.J. (1999) Should distal interlocking of tibial nails be performed from a medial or a lateral direction? anatomical and biomechanical considerations. Journal of Orthopaedic Trauma, 13, 27-32. doi:10.1097/00005131-199901000-00007 [17] Kneifel, T. and Buckley, R. (1996) A comparison of one versus two distal locking screws in tibial fractures treated with unreamed tibial nails: A prospective randomized clinical trial. Injury, 27, 271-273. doi:10.1016/0020-1383(95)00116-6 [18] George, C.J., Lindsey, R.W., Noble, P.C., Alexander, J.W. and Kamaric, E. (1998) Optimal location of a single distal interlocking screw in intramedullary nailing of distal third femoral shaft fractures. Journal of Orthopaedic Trauma, 12, 267-272. doi:10.1097/00005131-199805000-00009 [19] Gollwitzer, H., Karampour, K., Hauschild, M., Diehl, P., Busch, R. and Mittelmeier, W. (2004) Biomechanical investigation of the primary stability of intramedullary compression nails in the proximal tibia: Experimental study using interlocking screws in cryopreserved human tibias. Journal of Orthopaedic Science, 9, 22-28. [20] Heidemann, W., Gerlach, K.L., Gr?bel, K.H. and K?llner, H.G. (1998) Influence of different pilot hole sizes on torque measurements and pullout analysis of osteosynthesis screws. Journal of Cranio-maxillo-facial Surgery, 26, 50-55. doi:10.1016/S1010-5182(98)80035-8 [21] Heidemann, W., Gerlach, K.L., Gr?bel, K.H. and K?llner, H.G. (1998) Drill Free Screws: a new form of osteosynthesis screw. Journal of Cranio-maxillo-facial Surgery, 26, 163-168. doi:10.1016/S1010-5182(98)80007-3 [22] Osterkamp, L.K. (1995) Current perspective on assessment of human body proportions of relevance to amputees. Journal of the American Dietetic Association, 95, 215-218. doi:10.1016/S0002-8223(95)00050-X