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European Journal of Trauma and Emergency Surgery

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Open Access 30-07-2022 | Tibia Fracture | Original Article

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

Authors: Nils Jan Bleeker, Job N. Doornberg, Kaj ten Duis, Mostafa El Moumni, Inge H. F. Reininga, Ruurd L. Jaarsma, Frank F. A. IJpma, On behalf of the Traumaplatform 3D Consortium

Published in: European Journal of Trauma and Emergency Surgery | Issue 6/2023

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.

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Title: Intraoperative fluoroscopic protocol to avoid rotational malalignment after nailing of tibia shaft fractures: introduction of the ‘C-Arm Rotational View (CARV)’
Authors: Nils Jan Bleeker
Job N. Doornberg
Kaj ten Duis
Mostafa El Moumni
Inge H. F. Reininga
Ruurd L. Jaarsma
Frank F. A. IJpma
On behalf of the Traumaplatform 3D Consortium
Publication date: 30-07-2022
Publisher: Springer Berlin Heidelberg
Keyword: Tibia Fracture
Published in: European Journal of Trauma and Emergency Surgery / Issue 6/2023
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-022-02038-2

Keynote webinar | Spotlight on medication adherence

Springer Medicine

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

Abstract

Purpose

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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