Study on incidence of anterior ankle pain after distal tibial extra-articular fractures treated with retrograde tibial intramedullary nail_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

XIONG Yuanfei , LIU Hui , CHEN Tianlai , LIN Weibin , ZHANG Jinhui ,  WU Jin

Department of Orthopaedics, the 909th Hospital, Dongnan Hospital of Xiamen University, Zhangzhou Fujian, 363000, P. R. China;

Corresponding?author：

WU Jin, Email: wujin1983@xmu.edu.cn

Keywords：

Retrograde tibial intramedullary nail; distal tibial extra-articular fracture; anterior ankle pain

DOI：

10.7507/1002-1892.202508076

Video：

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Abstract Full text Figures/Tables Video References Cited by

Objective To investigate whether retrograde tibial intramedullary nail (RTN) fixation can cause postoperative anterior ankle pain in the treatment of distal tibial extra-articular fracture. Methods A retrospective analysis was performed for 29 patients with distal tibial extra-articular fractures caused by trauma, who received RTN treatment between January 2021 and December 2023. There were 19 males and 10 females, with an average age of 47.3 years. There were 18 cases of closed fractures and 11 cases of open fractures. The time from injury to hospital admission was 1-5 days, with an average of 3.7 days. The bone union time, time to full weight bearing, visual analogue scale (VAS) score, Olerud-Molander ankle score (OMAS), and occurrence of anterior ankle pain were recorded. Results The operation time was 43-75 minutes (mean, 60.7 minutes); intraoperative blood loss was 50-120 mL (mean, 88.3 mL). All patients were followed up 14-32 months (mean, 24.0 months). All patients achieved fracture healing and the healing time was 3-6 months (mean, 4.5 months). The postoperative full weight-bearing time was 40-63 days (mean, 53.3 days). The VAS scores were 0-5 (mean, 2.0) at 3 months after operation and 0-3 (mean, 1.5) at last follow-up. The OMAS scores were 60-95 (mean, 80.3) at last follow-up and the ankle functions were rated as excellent in 3 cases, good in 24, and fair in 2, with a excellent and good rate of 93.1%. The postoperative anterior ankle pain occurred in 2 patients (6.9%) and relieved after removal of RTN. Conclusion RTN treatment for distal tibial extra-articular fractures provides firm fixation, which is beneficial for early postoperative functional exercise and weight-bearing in patients, and has a lower incidence of anterior ankle pain.

1.	Li X, Chen K, Xue H, et al. Efficacy comparison between intramedullary nail fixation and plate fixation in distal tibia fractures: a meta-analysis of randomized controlled trials. J Orthop Surg Res, 2024, 19(1): 403. doi: 10.1186/s13018-024-04900-y.
2.	Wennergren D, Bergdahl C, Ekelund J, et al. Epidemiology and incidence of tibia fractures in the Swedish Fracture Register. Injury, 2018, 49(11): 2068-2074.
3.	葛振新, 王明法, 牛德剛, 等. 兩種術式治療脛骨遠端A型骨折的療效比較. 臨床骨科雜志, 2025, 28(4): 575-578.
4.	Gao F, Wang XH, Xia SL, et al. Intramedullary nail fixation by suprapatellar and infrapatellar approaches for treatment of distal tibial fractures. Orthop Surg, 2022, 14(9): 2350-2360.
5.	Erin-Madsen N, Aasvang TK, Viberg B, et al. Knee pain and associated complications after intramedullary nailing of tibial shaft fracture. Dan Med J, 2019, 66(8): A5554.
6.	廖云健, 黃佳, 尤加銳, 等. 不同入路行脛骨骨折髓內釘固定的療效比較及術后膝部疼痛原因分析. 實用骨科雜志, 2023, 29(12): 1081-1085.
7.	van de Pol GJ, Axelrod DE, Conyard C, et al. A suprapatellar approach, when compared with an infrapatellar approach, yields less anterior knee pain and better patellofemoral joint function, for intramedullary nailing of diaphyseal tibial fractures: results of a randomized controlled trial. J Orthop Trauma, 2024, 38(5): 235-239.
8.	Ahmad S, Ahmed A, Khan L, et al. Comparative analysis of anterior knee pain in transpatellar and medial parapatellar tendon approaches in tibial interlocking nailing. J Ayub Med Coll Abbottabad, 2016, 28(4): 694-697.
9.	Wang C, Chen E, Ye C, et al. Suprapatellar versus infrapatellar approach for tibia intramedullary nailing: A meta-analysis. Int J Surg, 2018, 51: 133-139.
10.	Beckwith M, Cushman D, Clark T, et al. Radiofrequency ablation of the infrapatellar branch of the saphenous nerve for the treatment of chronic anterior inferomedial knee pain. Pain Med, 2023, 24(2): 150-157.
11.	Soraganvi PC, Anand-Kumar BS, Rajagopalakrishnan R, et al. Anterior knee pain after tibial intra-medullary nailing: is it predictable? Malays Orthop J, 2016, 10(2): 16-20.
12.	王義昌, 林文杰, 林濤, 等. 脛骨遠端骨折三種內固定方式的有限元分析. 中國組織工程研究, 2023, 27(36): 5760-5765.
13.	何敏, 李正茂, 譚文甫, 等. 新型逆行脛骨髓內釘治療脛骨遠端骨折的初步療效分析. 中華創傷骨科雜志, 2022, 24(4): 334-338.
14.	Peng B, Wan T, Tan W, et al. Novel retrograde tibial intramedullary nailing for distal tibial fractures. Front Surg, 2022, 9: 899483. doi: 10.3389/fsurg.2022.899483.
15.	Liu H, Xu W, Xiong Y, et al. Distal tibial fractures fixation using retrograde tibial intramedullary nail in high-risk patients: a retrospective study. Acta Orthop Belg. 2024, 90(3): 559-565.
16.	Liu H, Xu W, Xiong Y, et al. Retrograde tibial intramedullary nail versus minimally invasive locking plate for extra-articular distal tibial fractures: a comparative and retrospective study. J Orthop Surg Res, 2024, 19(1): 481. doi: 10.1186/s13018-024-04979-3.
17.	Zhai WL, Xiong YF, Liu H, et al. Nonunion of the distal one-fourth of the tibia treated by retrograde tibial intramedullary nail. J Int Med Res, 2024, 52(10): 3000605241289017. doi: 10.1177/03000605241289017.
18.	Tse S, Saade A, Simister SK, et al. Clinical and radiographic outcomes of small caliber intramedullary nails for tibial shaft fractures. J Am Acad Orthop Surg Glob Res Rev, 2025, 9(2): e24.00389. doi: 10.5435/JAAOSGlobal-D-24-00389.
19.	Baker HP, Strelzow J, Dillman D. Tibial alignment following intramedullary nailing via three approaches. Eur J Orthop Surg Traumatol, 2022, 32(7): 1247-1255.
20.	Stedtfeld HW, Mittlmeier T, Landgraf P, et al. The logic and clinical applications of blocking screws. J Bone Joint Surg (Am), 2004, 86-A Suppl 2: 17-25.
21.	Kc KM, Pangeni BR, Marahatta SB, et al. Comparative study between intramedullary interlocking nailing and minimally invasive percutaneous plate osteosynthesis for distal tibia extra-articular fractures. Chin J Traumatol, 2022, 25(2): 90-94.
22.	Chun DI, Min TH, Kang EM, et al. Comparison of radiological and clinical outcomes in patients treated with standard plating versus intramedullary nailing in distal tibial fracture. Orthop Surg, 2022, 14(3): 536-542.
23.	張磊, 楊建成, 許喆, 等. 微創經皮鋼板與專家級脛骨髓內釘治療脛骨遠端干骺端骨折的進展. 實用骨科雜志, 2024, 30(12): 1095-1098.
24.	Hofmann G, Gonschorek O, Bühler M. et al. Retrograde nagelung der tibia. Trauma Und Berufskrankheit, 2001, 3(2 Supplement): S303-S308.
25.	Kuhn S, Appelmann P, Pairon P, et al. The retrograde tibial nail: presentation and biomechanical evaluation of a new concept in the treatment of distal tibia fractures. Injury, 2014, 45 Suppl 1: S81-S86.
26.	Lin X, Zhang C, Yang Y, et al. Comparative experimental study of the biomechanical properties of retrograde tibial nailing and distal tibia plate in distal tibia fracture. Front Bioeng Biotechnol, 2024, 12: 1322043. doi: 10.3389/fbioe.2024.1322043.
27.	Greenfield J, Appelmann P, Wunderlich F, et al. Retrograde tibial nailing of far distal tibia fractures: a biomechanical evaluation of double- versus triple-distal interlocking. Eur J Trauma Emerg Surg, 2022, 48(5): 3693-3700.
28.	Yamakawa Y, Uehara T, Shigemoto K, et al. Preliminary results of stabilization of far distal tibia fractures with the distal tibial nail: A prospective, multicenter case series study. Injury, 2024, 55(8): 111634. doi: 10.1016/j.injury.2024.111634.
29.	林偉斌, 劉暉, 徐維臻, 等. 脛骨逆行髓內釘治療脛骨遠端骨折療效及并發癥分析. 骨科, 2024, 15(6): 559-562.
30.	郝鵬, 杜傳超, 程華, 等. 維生素C對復雜性區域疼痛綜合征預防效果的Meta分析. 創傷外科雜志, 2016, 18(10): 595-598.

1. Li X, Chen K, Xue H, et al. Efficacy comparison between intramedullary nail fixation and plate fixation in distal tibia fractures: a meta-analysis of randomized controlled trials. J Orthop Surg Res, 2024, 19(1): 403. doi: 10.1186/s13018-024-04900-y.
2. Wennergren D, Bergdahl C, Ekelund J, et al. Epidemiology and incidence of tibia fractures in the Swedish Fracture Register. Injury, 2018, 49(11): 2068-2074.
3. 葛振新, 王明法, 牛德剛, 等. 兩種術式治療脛骨遠端A型骨折的療效比較. 臨床骨科雜志, 2025, 28(4): 575-578.
4. Gao F, Wang XH, Xia SL, et al. Intramedullary nail fixation by suprapatellar and infrapatellar approaches for treatment of distal tibial fractures. Orthop Surg, 2022, 14(9): 2350-2360.
5. Erin-Madsen N, Aasvang TK, Viberg B, et al. Knee pain and associated complications after intramedullary nailing of tibial shaft fracture. Dan Med J, 2019, 66(8): A5554.
6. 廖云健, 黃佳, 尤加銳, 等. 不同入路行脛骨骨折髓內釘固定的療效比較及術后膝部疼痛原因分析. 實用骨科雜志, 2023, 29(12): 1081-1085.
7. van de Pol GJ, Axelrod DE, Conyard C, et al. A suprapatellar approach, when compared with an infrapatellar approach, yields less anterior knee pain and better patellofemoral joint function, for intramedullary nailing of diaphyseal tibial fractures: results of a randomized controlled trial. J Orthop Trauma, 2024, 38(5): 235-239.
8. Ahmad S, Ahmed A, Khan L, et al. Comparative analysis of anterior knee pain in transpatellar and medial parapatellar tendon approaches in tibial interlocking nailing. J Ayub Med Coll Abbottabad, 2016, 28(4): 694-697.
9. Wang C, Chen E, Ye C, et al. Suprapatellar versus infrapatellar approach for tibia intramedullary nailing: A meta-analysis. Int J Surg, 2018, 51: 133-139.
10. Beckwith M, Cushman D, Clark T, et al. Radiofrequency ablation of the infrapatellar branch of the saphenous nerve for the treatment of chronic anterior inferomedial knee pain. Pain Med, 2023, 24(2): 150-157.
11. Soraganvi PC, Anand-Kumar BS, Rajagopalakrishnan R, et al. Anterior knee pain after tibial intra-medullary nailing: is it predictable? Malays Orthop J, 2016, 10(2): 16-20.
12. 王義昌, 林文杰, 林濤, 等. 脛骨遠端骨折三種內固定方式的有限元分析. 中國組織工程研究, 2023, 27(36): 5760-5765.
13. 何敏, 李正茂, 譚文甫, 等. 新型逆行脛骨髓內釘治療脛骨遠端骨折的初步療效分析. 中華創傷骨科雜志, 2022, 24(4): 334-338.
14. Peng B, Wan T, Tan W, et al. Novel retrograde tibial intramedullary nailing for distal tibial fractures. Front Surg, 2022, 9: 899483. doi: 10.3389/fsurg.2022.899483.
15. Liu H, Xu W, Xiong Y, et al. Distal tibial fractures fixation using retrograde tibial intramedullary nail in high-risk patients: a retrospective study. Acta Orthop Belg. 2024, 90(3): 559-565.
16. Liu H, Xu W, Xiong Y, et al. Retrograde tibial intramedullary nail versus minimally invasive locking plate for extra-articular distal tibial fractures: a comparative and retrospective study. J Orthop Surg Res, 2024, 19(1): 481. doi: 10.1186/s13018-024-04979-3.
17. Zhai WL, Xiong YF, Liu H, et al. Nonunion of the distal one-fourth of the tibia treated by retrograde tibial intramedullary nail. J Int Med Res, 2024, 52(10): 3000605241289017. doi: 10.1177/03000605241289017.
18. Tse S, Saade A, Simister SK, et al. Clinical and radiographic outcomes of small caliber intramedullary nails for tibial shaft fractures. J Am Acad Orthop Surg Glob Res Rev, 2025, 9(2): e24.00389. doi: 10.5435/JAAOSGlobal-D-24-00389.
19. Baker HP, Strelzow J, Dillman D. Tibial alignment following intramedullary nailing via three approaches. Eur J Orthop Surg Traumatol, 2022, 32(7): 1247-1255.
20. Stedtfeld HW, Mittlmeier T, Landgraf P, et al. The logic and clinical applications of blocking screws. J Bone Joint Surg (Am), 2004, 86-A Suppl 2: 17-25.
21. Kc KM, Pangeni BR, Marahatta SB, et al. Comparative study between intramedullary interlocking nailing and minimally invasive percutaneous plate osteosynthesis for distal tibia extra-articular fractures. Chin J Traumatol, 2022, 25(2): 90-94.
22. Chun DI, Min TH, Kang EM, et al. Comparison of radiological and clinical outcomes in patients treated with standard plating versus intramedullary nailing in distal tibial fracture. Orthop Surg, 2022, 14(3): 536-542.
23. 張磊, 楊建成, 許喆, 等. 微創經皮鋼板與專家級脛骨髓內釘治療脛骨遠端干骺端骨折的進展. 實用骨科雜志, 2024, 30(12): 1095-1098.
24. Hofmann G, Gonschorek O, Bühler M. et al. Retrograde nagelung der tibia. Trauma Und Berufskrankheit, 2001, 3(2 Supplement): S303-S308.
25. Kuhn S, Appelmann P, Pairon P, et al. The retrograde tibial nail: presentation and biomechanical evaluation of a new concept in the treatment of distal tibia fractures. Injury, 2014, 45 Suppl 1: S81-S86.
26. Lin X, Zhang C, Yang Y, et al. Comparative experimental study of the biomechanical properties of retrograde tibial nailing and distal tibia plate in distal tibia fracture. Front Bioeng Biotechnol, 2024, 12: 1322043. doi: 10.3389/fbioe.2024.1322043.
27. Greenfield J, Appelmann P, Wunderlich F, et al. Retrograde tibial nailing of far distal tibia fractures: a biomechanical evaluation of double- versus triple-distal interlocking. Eur J Trauma Emerg Surg, 2022, 48(5): 3693-3700.
28. Yamakawa Y, Uehara T, Shigemoto K, et al. Preliminary results of stabilization of far distal tibia fractures with the distal tibial nail: A prospective, multicenter case series study. Injury, 2024, 55(8): 111634. doi: 10.1016/j.injury.2024.111634.
29. 林偉斌, 劉暉, 徐維臻, 等. 脛骨逆行髓內釘治療脛骨遠端骨折療效及并發癥分析. 骨科, 2024, 15(6): 559-562.
30. 郝鵬, 杜傳超, 程華, 等. 維生素C對復雜性區域疼痛綜合征預防效果的Meta分析. 創傷外科雜志, 2016, 18(10): 595-598.

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Latest ArticlesStudy on incidence of anterior ankle pain after distal tibial extra-articular fractures treated with retrograde tibial intramedullary nail

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