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Retrograde Intramedullary Nailing for Distal Tibial Periankle Fractures
Technical Highlights and Clinical Value
Distal tibial periankle fractures are commonly seen in clinical practice, accounting for approximately 7.2%–32% of all tibial fractures. Extra-articular fractures of the distal third of the tibia account for about 14.5% of distal tibial fractures. This area lacks soft tissue protection, and over 50% of high-energy medial tibial injuries are open fractures. Due to the proximity of the distal tibia to the ankle joint, these fractures are often difficult to reduce and fixate, with poor local soft tissue coverage and blood supply, making them a particularly challenging type of traumatic fracture.
Distal tibial periankle fractures (within 10–11 cm above the ankle) account for 7.2%–32% of tibial fractures, with poor soft tissue coverage and vascularity. Traditional medial plating may lead to necrosis or infection.
Antegrade nails risk poor distal alignment; expert nails are complex and may offer limited stability.
The Distal Tibial Intramedullary Nail (DTN) is indicated for a variety of tibial conditions, including simple, spiral, comminuted, long oblique, and segmental shaft fractures (particularly of the distal tibia), as well as distal tibial metaphyseal fractures, non-/mal-unions; it may also be employed, often with specialized devices, for managing bone defects or limb length discrepancies (such as lengthening or shortening).
Short segment fractures of the distal tibia near the ankle, including closed/open fractures or fractures involving the distal 1/5 of the tibia or metaphysis (AO/OTA 43.A1, 43.A2, 43.A3)
Distal tibial fractures involving the ankle joint (AO/OTA 43.C1, 43.C2), such as Pilon fractures. The indications are similar to DTN.
AO/OTA 43.A1–A3 (extra-articular fractures), 43.C1–C2 (partial intra-articular fractures)
Cases with ipsilateral knee replacement that preclude antegrade nail insertion
Severely comminuted Pilon fractures involving the articular surface
Severely contaminated wounds (Gustilo type III)
Severe osteoporosis
Local soft tissue or bone infections, long-segment defects, or pathological fractures
Under epidural or general anesthesia, the patient is placed supine. A pneumatic tourniquet (60 kPa) is applied to the proximal thigh. After standard disinfection and draping, closed reduction is attempted with fluoroscopy; reduction clamps or minimally invasive tools may be used. The entry point at the medial malleolus is confirmed fluoroscopically: on the AP view, it is 4 mm (for φ7 nail) or 5 mm (for φ8 nail) above the medial cortex; on the lateral view, it aligns with the central axis of the medial malleolus.
Entry point: AP view – 4 mm (φ7) or 5 mm (φ8) above medial cortex; lateral view – central axis of medial malleolus
Incision: 2 cm medial longitudinal cut, deltoid ligament split, sleeve placement
Reduction and nailing:
Fix fibula first if fractured
Insert guide pin parallel to medial cortex
Ream and insert nail; lock with 5 screws (3 distal cancellous, 2 proximal cortical)
Minimally invasive: subcutaneous operation preserves soft tissue, reduces infection
Biomechanical stability:
Medial curvature disperses stress, limits deformity (supported by Kuhn et al.)
Combined with fibular fixation, improves axial/torsional strength (Bonnevialle et al.)
Convenient: short learning curve, no costly tools required
Limited range (25–95 mm above ankle)
Entry risks injuring the saphenous vein or tarsal tunnel
Cannot directly compress fracture; lateral column relies on fibula fixation
Ankle pump exercises and straight leg raises begin 24 hours post-op
Gradual weight-bearing: partial at 6 weeks, full at 3 months (based on fracture type)
Routine anticoagulation to prevent deep vein thrombosis
Broad-spectrum antibiotics for open fractures during perioperative period
Avoid syndesmotic injury by precisely angling distal locking screws
" With anatomical adaptability and minimally invasive technique, retrograde tibial intramedullary nailing significantly improves reduction quality and early rehabilitation efficiency in distal periankle fractures. It provides a reliable solution for high-energy injuries in patients with fragile soft tissue conditions. "
Gao Mingming, Liu Qingjun, Zhu Jianfei, et al. Retrograde Intramedullary Nailing for Distal Tibial Periankle Fractures [J]. Chinese Journal of Orthopaedics, 2024, 44(19): 1280–1287.
