Injury, Int. J. Care Injured (2007) 38, 223—226

www.elsevier.com/locate/injury

Complications associated with the use ofa titanium tibial nail

Helen Young a,*, Claire Topliss b

aDepartment of Radiology, Bristol Royal Infirmary, Bristol, BS2 8BJ, United KingdombDepartment of Trauma and Orthopedics, Frenchay Hospital, North Bristol NHS Trust,Bristol, BS16 1LE, United Kingdom

Accepted 27 September 2006

KEYWORDSTibial Nail;Titanium;Complications

Summary Intramedullary nailing is the treatment of choice for unstable or dis-placed tibial fractures. Titanium nails have been advocated for their improvedbiocompatibility and biomechanical properties but concerns are held about increasedcomplications. We present results of 225 tibial fractures in 221 patients (90% follow-up) treated with the ACE titanium tibial nail (DePuy International Limited, Leeds, UK)inserted between 1995 and 2003 in one hospital department, which show no increasedcomplications compared with the published literature.

Eighty-two percent of the patients were male with a median age of 33 years. Themechanism of injury was RTA (52%), Sport (22%) and other (26%). Forty-one percent ofthe fractures were open. The general complication rate represents the publishedliterature whereas only 32% patients developed knee pain compared with the 40—57%previously reported. Median union time was unaffected by open injury, reaming orage. Ninety (43.3%) patients required re-operation of which 23 (11%) had a second re-operation. In total 43 (20.7%) nails were removed, without any complication aspreviously reported for this nail.# 2006 Elsevier Ltd. All rights reserved.

Introduction

Intramedullary nailing has become the treatment ofchoice of the majority of unstable or displaced tibialfractures3. There are a number of different types of

* Corresponding author. Tel.: +44 117 9276998.E-mail address: helenyoung80@hotmail.com (H. Young).

0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights resedoi:10.1016/j.injury.2006.09.018

nail available which can be made of a number ofdifferent materials. The use of a titanium nail hasbeen advocated for its improved biocompatibilityand biomechanical properties1 but concerns havebeen raised whether it would lead to increasedcomplications. The results of the ACE titanium tibialnail (DePuy International Limited, Leeds, UK)inserted between 1995 and 2003 in one hospitaldepartment are presented.

rved.

224 H. Young, C. Topliss

Table 2 Reasons for re-operation with numbers

Reason forre-operation

First(n = 90)

Second(n = 23)

Knee pain 26 (28.9%) 5 (21.7%)Pain from screws 13 (14%) 5 (21.7%)Delayed union 27 (30%) 4 (17.4%)Infection 3 (3.3%) 3 (13%)Patient request 7 (7.8%) 1 (4.3%)Broken screws 3 (3.3%)Not stated 3 (3.3%) 3 (13%)Others 8 (8.9%) 2 (8.6%)

Patients and methods

All patients treated with an ACE intramedullarytibial nail between June 1995 and February 2003,were included. Patients were identified from theoperating department records and data retrievedretrospectively from the clinical records. The fol-lowing data were recorded: patient demographics,injury details, operating surgeon, technique(reamed/unreamed), prosthesis size and numberof screws, post-operative complications, length ofhospital stay, time to partial and full weight bearing.Time to union is difficult to ascertain accurately; inthis series it was taken as the clinic date when thefracture was deemed to be both clinically and radi-ologically united. Data were analysed with StatView(SAS Institute Inc., Cary, USA).

Results

225 tibial fractures in 221 patients were treatedwith an ACE intramedullary nail. Notes were una-vailable for 17 patients and 6 patients failed toattend follow up. Patient demographics and injurydetails are shown in Table 1, open injuries aregraded according to the classification system ofGustilo et al.5,6 Grade of operating surgeon was aconsultant in 59 (28.8%) cases, registrar in 118(57.6%) cases, staff grade in 19 (9.3%) cases and aclinical fellow in 9 (4.4%) cases.

Themedian hospital staywas 8 days (range 1—161)and the median length of follow up was 14 months(range 3 weeks — 75 months). The post-operativecomplications were; 12 (5.8%) compartment

Table 1 Patient demographics and injury details

Gender 170 (82%) male,37 (18%) female

Age — median (range) 33 (15—91)

Mechanism of injuryRTA 105Football/rugby 44Fall 37Other 18Not recorded 4

Open injuries 81 (41%)Type 1 15 (19%)Type 2 9 (11%)Type 3A 25 (31%)Type 3B 22 (27%)Type 3C 1 (1%)Not recorded 9 (11%)

Associated injuries 68

syndromes, 9 (4.3%) cases of fat embolism, 3(1.4%) deep vein thromboses (DVT), 19 (9.1%) super-ficial infections and 6 (2.9%) deep infections. Therewas no association between the presence of an openinjury and the development of infection (Chi square:p = 0.1579). Sixty-six (31.7%) patients reported kneepain. Regarding the implants there were 8 brokenscrews (1 proximal and7 distal) in 7 cases; therewereno cases of a broken nail. There were 5 (2.4%) earlydeaths–—3 in elderly patients (2 from pneumonia and1 from metastatic bladder cancer) and 2 in youngpatients (head injury).

The median time to partial weight bearing was3.8 weeks and to full weight bearing was 11.2weeks. Time to union data was available for 68patients. The data was inexact due to the infrequentattendance at clinic (i.e. seen at three monthlyintervals). The median time was 8.6 months (range2.8—36). Time to union did not appear to beaffected by the presence of an open injury(Mann—Whitney: p = 0.9204), reaming (Mann—Whit-ney: p = 0.7736) or age of the patient (Spearman’sRank Correlation: p = 0.7173).

Ninety (43.3%) patients required re-operation ofwhich 23 (11%) had a second re-operation. Thereasons for re-operation are summarised inTable 2 and the type of re-operation in Table 3.

Table 3 Type of re-operation with numbers

Type of re-operation First(n = 90)

Second(n = 23)

Removal of distal lockingscrews only

16 (17.8%) 4 (17.3%)

Removal of proximal lockingscrews only (dynamisation)

12 (13.1%) 1 (4.3%)

Removal of proximal anddistal locking screws

14 (15.6%)

Removal of nail 32 (35.6%) 11 (47.8%)Exchange nailing 6 (6.7%)Bone grafting 3 (3.3%) 1 (4.3%)Others 7 (7.8%) 6 (26.1%)

Complications associated with the use of a titanium tibial nail 225

Table 4 Comparison of outcomes with reported literature (all numbers are percentages)

Study Court-Brown19903

Keating199710

Keating19978

Keating19979

Gaebler20014

Haddad19967

Bristol2005

Number in series 125 110 112 94 467 29 208Superficial infection 2.1 9.1Deep infection 1.6 1.8 5 3.2 1.1 3.4 2.9Anterior knee pain 40.8 57 57 45 55 31.7Re-operation rate 47 43.3Nail removal 26.4 46 46 31.5 38 20.7Compartment syndrome 3.2 5.4 7 3.2 13.3 0 5.8Fat embolism 3 3.2 4.3DVT 0.8 1.4Death 1.7 2.4

In total 43 (20.7%) nails were removed. On thewhole this procedure was not associated with anydifficulty; however, in one case post-operativecheck radiographs showed a hairline fracture, con-servative treatment was successful (Table 4).

Discussion

The results show the use of a titanium nail has noincrease in complications compared with the pub-lished literature.

Tibial fracture on removal of the ACE tibial nailhas previously been reported in four patients.12 Inthis reported series, of the 21 patients treated 19had the nail removed, four of which fractured.These fractures occurred in the posterior wall witha similar pattern in all four. It was thought to be dueto the posterior slot in the nail which has since beenmodified.

A further study investigating the outcome ofintramedullary nail removal2 reviewed 51 tibialnails. Twenty had been removed for pain, threefor infection and in 22 no indication was recorded.This series reported one tibial fracture on removal,caused by failure to remove the distal locking screwprior to extraction.

The occurrence of anterior knee pain is welldescribed with tibial intramedullary nailing, theincidence reported between 40 and 57%(Table 3). In our series, knee pain was evident inonly 32%. If this is compared with the average rateof knee pain in the published studies (Table 3) of50.9% the risk ratio for anterior knee pain is 0.62suggesting that 38% fewer patients treated with thetitanium tibial nail will suffer from anterior kneepain. Knee pain is often an indication for nailremoval but evidence suggests that this is notalways beneficial. Boerger et al.2 removed 16 nailsfor anterior knee pain, only nine had an improve-ment in their symptoms, and worse still four

patients who were previously asymptomatic devel-oped knee pain after removal. Patients with ante-rior knee pain should be told that there pain maypersist and that painmay even arise with removal ofa nail.

It has previously been suggested that reamingmay increase the risk of fat embolism11 but weare unable to support this. We found that fat embo-lism occurred in both the reamed and unreamedgroups (Fisher’s exact p value >0.999).

Limitations of the study are that it is retrospec-tive, union time is difficult to measure due to infre-quent follow-up and the definitive re-operation ormetalwork removal was only offered to those whohad symptoms.

Conclusions

The use of a titanium nail shows similar results as toother stainless steel nails in the literature. Thereported incidence of complications with itsremoval in previous reports has not been our experi-ence.

References

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226 H. Young, C. Topliss

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