Tse Shannon, Saade Aziz, Simister Samuel K, McKeithan Lydia J, White Micaela, Dejenie Rebeka, Brooks Branden, Bhale Rahul, Campbell Sean T, Fitzpatrick Ellen, Soles Gillian L, Lee Mark A, Saiz Augustine M
From the Department of Orthopaedic Surgery, University of California Davis (Dr. Tse, Dr. Saade, Dr. Simister, Dr. McKeithan, Dr. Bhale, Dr. Campbell, Dr. Fitzpatrick, Dr. Soles, Dr. Lee, and Dr. Saiz); and the University of California Davis School of Medicine (Ms. White, Ms. Dejenie, and Mr. Brooks), Sacramento, CA.
J Am Acad Orthop Surg Glob Res Rev. 2025 Jan 29;9(2). doi: 10.5435/JAAOSGlobal-D-24-00389. eCollection 2025 Feb 1.
Tibial shaft fractures, frequently treated with intramedullary nailing (IMN), are high-risk fractures of nonunion. The effect of intramedullary nail diameter on fracture union reduction remains an area of investigation, with many surgeons anecdotally preferring to place at least a 10-mm tibial nail. We hypothesized that small-caliber nails (SCNs) (diameter ≤9 mm) are safe to use and have no difference in complication rates compared with large-caliber nails (LCNs) (≥10 mm).
A retrospective study was conducted on patients with tibial shaft fractures undergoing reamed IMN at a level 1 trauma center between 2018 and 2022. Patient and injury characteristics, intramedullary nail diameter, surgical details, and postoperative complication rates were recorded. Nail and intramedullary canal width at the isthmus on coronal radiographs determined the nail-canal ratio. Radiographic coronal and sagittal displacement, angulations between fracture segments, and coronal plane tibial mechanical axis were evaluated on latest radiographs.
Among 113 patients, 68 received SCN while 45 received LCN. No difference was observed in the nail-canal ratio between the SCN and LCN groups, indicating that smaller nails were used for smaller canals. No significant demographic differences were noted between groups. LCNs were more prevalent in (AO Foundation/Orthopaedic Trauma Association classification) AO/OTA 42C (P = 0.03) and Gustilo-Anderson type III fractures (P = 0.05). The LCN group had higher rates of revision surgery (20% vs. 5.9%, P = 0.03) and wound dehiscence (8.9% vs. 0%, P = 0.02). Gustilo-Anderson IIIA fractures were independently associated with poorer outcomes overall. Radiographic parameters were comparable between groups.
Small-diameter and large-diameter reamed intramedullary nails can be effective in treating tibial shaft fractures. Nail-canal ratios and alignment were similar between the two groups, suggesting that surgeons should not feel obligated to ream to a 10-mm nail in a smaller patient with a well-reduced fracture.
胫骨干骨折常采用髓内钉固定（IMN）治疗，是发生骨不连的高风险骨折。髓内钉直径对骨折愈合的影响仍是一个研究领域，许多外科医生凭经验更倾向于置入至少10毫米的胫骨髓内钉。我们假设小口径髓内钉（SCNs）（直径≤9毫米）使用安全，与大口径髓内钉（LCNs）（≥10毫米）相比，并发症发生率无差异。
对2018年至2022年在一级创伤中心接受扩髓IMN治疗的胫骨干骨折患者进行回顾性研究。记录患者和损伤特征、髓内钉直径、手术细节和术后并发症发生率。冠状位X线片上峡部的髓内钉和髓腔宽度确定钉-腔比。在最新的X线片上评估骨折段之间的X线冠状位和矢状位移位、成角以及冠状面胫骨机械轴。
113例患者中，68例接受SCN，45例接受LCN。SCN组和LCN组的钉-腔比无差异，表明较细的髓内钉用于较窄的髓腔。两组间未观察到显著的人口统计学差异。LCN在（AO基金会/骨科创伤协会分类）AO/OTA 42C型骨折（P = 0.03）和 Gustilo-Anderson III型骨折（P = 0.05）中更常见。LCN组翻修手术率（20%对5.9%，P = 0.03）和伤口裂开率（8.9%对0%，P = 0.02）更高。Gustilo-Anderson IIIA型骨折总体上与较差的预后独立相关。两组间的影像学参数具有可比性。
小直径和大直径扩髓髓内钉均可有效治疗胫骨干骨折。两组间的钉-腔比和对线情况相似，这表明对于骨折复位良好的体型较小的患者，外科医生不必觉得有必要扩髓至10毫米的髓内钉。
