gms | German Medical Science

Objectives: Feasibility and Effectiveness of extension-intramedullary nail tibia (Precise) in long bone pseudarthrosis. We present our clinics first case of extension-intramedullary nail in the following patient:

A 40-year-old male collided with a forthcoming car in a motor vehicle accident sustaining a 3a (Gustillo-Anderson) open lower limb fracture (AO: 42 C3) on the right side. Initial operative treatment was temporary external fixation following intramedullary osteosynthesis of the tibia (ETN 8mm) and plate osteosynthesis of the fibula (LCP). After three months low pulsed ultrasound therapy was induced and dynamization of the ETN was performed 6 months after surgery.

At presentation the right leg was 3 cm shorter with clinical signs of internal rotation with gait abnormality.X-ray imaging showed a hypertrophic pseudarthrosis of the proximal tibia (Figure 1/1 [Fig. 1]) and a broken proximal bolt. We performed a preoperative CT to assess leg torsion difference. External rotation was 1,9° for the right and 35,4° for the left leg.

Methods: We conducted the following operation on the right lower limb: Metal removement of the (lossed) ETN tibia with corticotomie, 20° external de-rotation, metal removement LCP fibula and corticotomie, implantation of extension-intramedullary nail tibia (Precise 365/10,7). An internal cancellous bone graft of the tibial pseudarthrosis is achieved through reaming of the medullary cavity (up to 12,5 mm). There were no macroscopic or microbiologic signs of infection.

Distraction was performed at 0,5 mm/day (0,25 mm 2x/day) starting at postoperative day 10 and planned for 50 days. After surgery and during distraction the right leg was unloaded.

Results and conclusion: A postoperative torsion CT scan showed physiologic external rotation of 31,5° on both legs. Figure 1/2 [Fig. 1] shows the postoperative results prior to distraction. Figure 1/3 [Fig. 1] shows the radiologic and clinical results at the end of the 49-day long distraction phase.

After the distraction period, partial weight-bearing of 20 kg was performed for 6 weeks. Afterwards weight-bearing was increased by 10-15 kg/week and full weight-bearing and return to work was achieved after another 6 weeks.

At 8 month follow-up the following parameters were assessed: right knee: ex/flex: 0-10-140°, upper ancle joint: pronation: 10-0-40°, supination 15-0-20°, one-leg-stand and standing on toes securely demonstrated on both sides, walking-time up to 2 h. Figure 1/4 [Fig. 1] shows the complete ossification at the tibial distraction sight at 1 year follow up with correctly implanted intramedullary nail and correct axis position. The patient is pain-free without analgesics since.