Simultaneous Surgical Management of Acute Tibial Shaft Fracture and Post-traumatic Ankle Arthritis - Cureus

Tibial shaft fractures are terrible injuries that could effect successful complications specified arsenic acute compartment syndrome, heavy vein thrombosis, infection, nonaccomplishment of alignment, nervus injury, nonunion, reduced mobility, and imperishable disablement [1-5]. The golden modular surgical process for tibial shaft fractures is reamed intramedullary nailing [1,6]. However, a hunt successful the lit did not output results regarding the absorption of acute tibial shaft fracture combined with post-traumatic ankle arthritis with ankle symptom arsenic the main complaint. Post-traumatic ankle arthritis develops secondary to associated trauma and is usually managed by either full ankle replacement oregon ankle arthrodesis [7].

Managing a tibial shaft fracture combined with post-traumatic ankle arthritis with ankle symptom arsenic the main ailment tin beryllium challenging; a thorough hunt of the erstwhile lit failed to reproduce immoderate results pertaining to this combination. One imaginable solution is to simultaneously execute closed simplification and interior fixation (CRIF) and tibiotalocalcaneal arthrodesis (TTCA) utilizing a retrograde femoral nail to execute a unchangeable and pain-free relation of the little limb. The instrumentality chosen, though it violates the subtalar joint, fixates the tibial fracture, manages terrible ankle arthritis, and, if done correctly, establishes and maintains due lower-limb alignment. To the champion of our knowledge, the erstwhile lit does not picture a lawsuit utilizing the aforesaid method for the aforesaid purpose.

This lawsuit study demonstrates the surgical method and outcomes of CRIF and TTCA utilizing a retrograde femoral nail successful a diligent with a close spiral tibial shaft fracture and terrible post-traumatic ankle arthritis.

A 71-year-old antheral diligent with a past of benignant II diabetes mellitus, hypertension, and dyslipidemia presented to the exigency section (ED) with a main ailment of symptom successful his close limb and ankle aft falling retired of furniture and twisting his ankle. The limb symptom started aft the injury; however, helium suffered from terrible ankle symptom 2 years earlier the injury, which prevented him from ambulating extracurricular his house. This long-lasting ankle symptom started aft a erstwhile close ankle fracture, which was managed by unfastened simplification and interior fixation (ORIF) 3 years earlier this visit. He was pursuing with podiatry successful a peripheral municipality and was lone offered boots, to which helium did not respond precise well. 

Physical introspection revealed that helium was connected a splint from the exigency aesculapian services. His close ankle was swollen and edematous, with tenderness implicit the proximal lateral and distal medial limb and ankle tenderness, indicating the beingness of an wounded and the value of his ankle arthritis. Furthermore, the posterior tibial and dorsalis pedis arteries were not palpable, but they were triphasic connected Doppler ultrasound. Moreover, the diligent was capable to determination his ft and toes, and the sensation was intact.

Radiographs of the patient’s close tibia, fibula, and ankle were taken by the ED and are shown successful Figures 1, 2. Radiographs of the tibia and fibula showed a comminuted and mildly displaced proximal fibular fracture and tibial spiral fracture with medial displacement of the distal shaft of the tibia. Ankle radiography showed post-ORIF presumption with plates and screws transfixing distal fibular fracture with pulled-out screws. Moreover, radiography showed terrible tibiotalar post-traumatic arthritis.

The diligent was admitted to our infirmary with an above-knee backslab. Subsequently, preoperative clearance was performed. An corruption workup was conducted, and it was negative. He underwent closed simplification of the close tibia and ankle with retrograde nailing done the calcaneus utilizing a retrograde femoral nail to fuse the ankle and fixate the fracture (Figure 3). He tolerated the process without complications and was referred for physiotherapy for non-weight-bearing connected the close side, nary ankle scope of question (ROM), and full-knee ROM.

He started mobilizing with walking frames 3 days aft the process and was discharged the adjacent day. The diligent was discharged with regular follow-ups. At the three-month follow-up, the bony national was achieved with a resulting mean pullout of the lateral to medial screw astatine the calcaneus level that was asymptomatic. The aesculapian squad has discussed the anticipation of follow-up removal surgery, but the diligent is against it arsenic helium was not bothered by it, adjacent though it tin beryllium felt nether the skin. Full value bearing, arsenic tolerated, was started 3 months aft the surgery. Five and a fractional months aft the surgery, helium was utilizing a cane; however, helium could locomotion without it. Around 9 months aft the procedure, the diligent was actively mobile with afloat value bearing. At the latest follow-up, 17 months aft the surgery, the diligent was doing good with nary complaints oregon weight-bearing restrictions connected the close ankle. In addition, the diligent nary longer complained of ankle pain. Radiographs of the tibia, fibula, and ankle astatine the latest follow-up are shown successful Figures 4, 5, respectively.

Surgical technique

The diligent was placed successful a supine position, with his ankle hanging from the borderline of the bed. Usually, positioning the diligent successful a prone presumption makes the process easier. However, owed to the patient’s value and comorbidities, the anesthesia squad preferred to bash it nether determination anesthesia with the diligent supine to show him. It was done successful the supine presumption with hep and genu flexion. An incision was made connected the fibular broadside of the syndesmotic screw nether radiographic guidance. The syndesmotic and fibular pulled-out locking screws from the erstwhile fixation were removed. Subsequently, a plantar-based incision successful enactment with the talus and tibia was made nether radiographic guidance. A guidewire was inserted nether radiographic guidance done the calcaneus, talus, and tibia.

Subsequently, a proximal reamer was utilized to unfastened the pathway for the ball-tipped guidewire, which was introduced up to the proximal tibia. Next, the reaming was started with 9 to 13 utilizing a flexible powerfulness reamer. The magnitude measurements were past taken astatine 400 mm, and the nail was inserted (retrograde femoral nail size [11.5 × 400 mm]). Distal screws were inserted done the calcaneus and the talus, followed by the insertion of a proximal screw into the nail.

Finally, radiographs of the fracture and ankle associated were taken, which showed satisfactory alignment. Forward hammering aft the distal interlocking screw closed the fracture spread archetypal definitely, past closed the tiny spread astatine the associated level eventually, which gave the last compression astatine some sites.

We decided to bash a simultaneous tibial CRIF and TTCA due to the fact that the diligent presented with ankle symptom arsenic the main complaint. Furthermore, helium stated the value of dealing with his ankle symptom earlier dealing with his leg. Therefore, we seized the accidental to dainty some utilizing a azygous conception erstwhile and for all.

Most tibial shaft fractures hap successful young and progressive patients and effect from high-energy trauma, specified arsenic centrifugal conveyance accidents oregon falls from tallness [1]. However, the 2nd highest of incidence is seen among aged patients whose injuries astir apt effect from a elemental autumn [1]. These fractures are mostly managed with CRIF utilizing an intramedullary nailing method [1]. Reaming earlier nailing lowers the incidence of implant nonaccomplishment [6]. Therefore, reaming was done successful our case.

We preferred utilizing a femoral nail due to the fact that femoral nails supply a broad size scope successful presumption of magnitude and diameter and person little inherent angulation. Moreover, the usage of femoral nails for TTCA has been good documented successful the lit with fantabulous results [7-10]. In a prospective survey [9], TTCA was performed utilizing a retrograde femoral nail among 29 patients and showed that the mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score accrued from 46 to 71 aft surgery. Furthermore, utilizing the 36-Item Short Form Health Survey Questionnaire, earlier the surgery, 73% of patients reported that their carnal and intelligence wellness interfered with societal activities immoderate of the time. However, aft the surgery, 86% of them rated their wide wellness arsenic fantabulous oregon good, 79% of patients reported little oregon nary symptom successful the ankle and subtalar joints, and 82% had immoderate improvements successful prime of beingness aft the surgery. Nevertheless, we could not find immoderate erstwhile probe demonstrating the outcomes of utilizing a femoral nail to hole a tibial shaft fracture and ankle arthrodesis.

We performed the country utilizing a retrograde femoral nail due to the fact that it does not invade the proximal tibia, which mightiness compromise its strength. Moreover, according to a prospective survey by Goebel et al. [10], the retrograde attack results successful a higher complaint of bony consolidation. The survey included 20 patients who underwent TTCA utilizing the retrograde attack and 20 who underwent TTCA utilizing an antegrade approach. The results showed that the complaint of bony consolidation was 95% successful the retrograde radical and 85% successful the anterograde group. However, some groups demonstrated betterment successful symptom and prime of life.

Some limitations of this method are that it is technically demanding owed to the patient's presumption and ensuring the due alignment and compression of the fracture and the joint. Furthermore, reaming would beryllium challenging if the intramedullary canal diameter is little than 7 mm [11]. Moreover, this method would not beryllium imaginable if the intramedullary canal is deformed. On the different hand, 1 of the advantages of this method is that the interior fixation tin beryllium dynamized. Furthermore, this method successful our diligent resulted successful important symptom betterment with the attraction of due hindfoot and midfoot alignment.

The patient's ankle symptom improved importantly aft surgery, and the tibial fracture healed adequately. In addition, the diligent could afloat carnivore value connected his ankle without immoderate complaints astatine the three-month follow-up.