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      Intraoperative fluoroscopic protocol to avoid rotational malalignment after nailing of tibia shaft fractures: introduction of the ‘C-Arm Rotational View (CARV)’

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          Abstract

          Purpose

          Rotational malalignment (≥ 10°) is a frequent pitfall of intramedullary-nailing of tibial shaft fractures. This study aimed to develop an intraoperative fluoroscopy protocol, coined ‘C-Arm Rotational View (CARV)’, to significantly reduce the risk for rotational malalignment and to test its clinical feasibility.

          Methods

          A cadaver and clinical feasibility study was conducted to develop the CARV-technique, that included a standardized intraoperative fluoroscopy sequence of predefined landmarks on the uninjured and injured leg in which the rotation of the C-arm was used to verify for rotational alignment. A mid-shaft tibia fracture was simulated in a cadaver and an unlocked intramedullary-nail was inserted. Random degrees of rotational malalignment were applied using a hand-held goniometer via reference wires at the fracture site. Ten surgeons, blinded for the applied rotation, performed rotational corrections according to (1) current clinical practice after single-leg and dual-leg draping, and (2) according to the CARV-protocol. The primary outcome measure was the accuracy of the corrections relative to neutral tibial alignment. The CARV-protocol was tested in a small clinical cohort.

          Results

          In total, 180 rotational corrections were performed by 10 surgeons. Correction according to clinical practice using single-leg and dual-leg draping resulted in a median difference of, respectively, 10.0° (IQR 5.0°) and 10.0° (IQR 5.0°) relative to neutral alignment. Single-leg and dual-leg draping resulted in malalignment (≥10°) in, respectively, 67% and 58% of the corrections. Standardized correction using the CARV resulted in a median difference of 5.0° (IQR 5.0°) relative to neutral alignment, with only 12% categorized as malalignment (≥10°). The incidence of rotational malalignment after application of the CARV decreased from 67% and 58% to 12% ( p =  <0.001). Both consultants and residents successfully applied the CARV-protocol. Finally, three clinical patients with a tibial shaft fracture were treated according to the CARV-protocol, resulting all in acceptable alignment (<10°) based on postoperative CT-measurements.

          Conclusion

          This study introduces an easy-to-use and clinically feasible standardized intraoperative fluoroscopy protocol coined ‘C-arm rotational view (CARV)’ to minimize the risk for rotational malalignment following intramedullary-nailing of tibial shaft fractures.

          Supplementary Information

          The online version contains supplementary material available at 10.1007/s00068-022-02038-2.

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          Most cited references27

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          Normal Foot and Ankle Radiographic Angles, Measurements, and Reference Points.

          The limb deformity-based principles originate from a standard set of lower extremity radiographic angles and reference points. Objective radiographic measures are the building blocks for surgical planning. Critical preoperative planning and intraoperative and postoperative evaluation of radiographs are essential for proper deformity planning and correction of all foot and ankle cases. A total of 33 angles and reference points were measured on 24 healthy feet. The radiographic measurements were performed on standard weightbearing anteroposterior, lateral, and axial views of the right foot. A total of 4 measurements were made from the axial view, 12 from the lateral view, and 17 from the anteroposterior view. All angles were measured by both senior authors twice, independent of each other. The radiographic angles and measurements presented in the present study demonstrate a comprehensive and useful set of standard angles, measures, and reference points that can be used in clinical and perioperative evaluation of the foot and ankle. The standard radiographic measures presented in the present study provide the foundation for understanding the osseous foot and ankle position in a normal population.
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            Rotational malalignment of the tibia following reamed intramedullary nail fixation.

            To determine the incidence and severity of tibial malrotation following reamed intramedullary nail fixation as measured by computerized tomography and to determine the repeatability of computed tomography measurement in the assessment of rotational malreduction. Prospective cohort. Level 1 trauma center. Twenty-five consecutive patients with 25 tibial shaft fractures. All patients were treated with reamed intramedullary nailing. Appropriate radiographs and a postoperative lower extremity computed tomography scan were obtained for each patient who consented to the study. Rotational alignment of affected tibia as compared to a version of the normal contralateral limb. Malrotation was defined as an internal/external rotation deformity greater than 10degrees. Malrotation, comparing the fractured limb to normal limb, was determined using a similar measurement method previously described in the literature. Two patients declined inclusion, and in one case, the computed tomography was not acceptable for analysis. Malrotation, comparing the fractured limb to the normal limb, was determined using the measurements from axial computed tomography images. Results revealed a mean absolute rotational difference of 6.7degrees (SD +/-6.3degrees). Rotational malreduction ranged from 15degrees of internal rotation to 22degrees of external rotation. Five of the 22 tibia (22%) were malrotated greater than 10degrees. A larger degree of deformity was seen with certain injury patterns. The intraobserver and interobserver repeatability testing revealed a mean absolute difference between paired malrotation calculations of 3.4degrees and 3.9degrees, respectively, and a repeatability coefficient of 8degrees for both. Computed tomography measurement is a repeatable method of assessing tibial torsion and in this study revealed a significantly higher incidence of rotational malreduction than that previously reported in the literature.
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              Intramedullary nailing versus minimally invasive plate osteosynthesis for distal extra-articular tibial fractures: a prospective randomized clinical trial.

              The purpose of this randomized clinical trial is to compare intramedullary nailing (IMN) versus minimally invasive plate osteosynthesis (MIPO) for the treatment of extra-articular distal tibial shaft fractures.
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                Author and article information

                Contributors
                n.j.bleeker@umcg.nl
                Journal
                Eur J Trauma Emerg Surg
                Eur J Trauma Emerg Surg
                European Journal of Trauma and Emergency Surgery
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                1863-9933
                1863-9941
                30 July 2022
                30 July 2022
                2023
                : 49
                : 6
                : 2329-2336
                Affiliations
                [1 ]GRID grid.4830.f, ISNI 0000 0004 0407 1981, Department of Orthopaedic Trauma Surgery, , University Medical Center Groningen, University of Groningen, ; Groningen, The Netherlands
                [2 ]Department of Orthopaedic Trauma Surgery, Flinders Medical Center and Flinders University, ( https://ror.org/01kpzv902) Adelaide, Australia
                Author information
                http://orcid.org/0000-0002-1221-6058
                Article
                2038
                10.1007/s00068-022-02038-2
                10728226
                35907028
                e7446149-9be1-468f-9e63-dd7076f4835f
                © The Author(s) 2022, corrected publication 2022

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 9 May 2022
                : 26 June 2022
                Categories
                Original Article
                Custom metadata
                © Springer-Verlag GmbH Germany, part of Springer Nature 2023

                Emergency medicine & Trauma
                intramedullary-nailing,tibia shaft fractures,rotational malalignment,‘c-arm rotational view (carv)’

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