Kirschner wires as blocking screws in extra-articular fractures of the distal tibia treated with intramedullary nail

Kirschner wires as blocking screws in extra-articular fractures of the distal tibia treated with intramedullary nail | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Kirschner wires as blocking screws in extra-articular fractures of the distal tibia treated with intramedullary nail Jun Liu, Simin Dai, Lijin Liu, Hailin Kuang, Liang Yan, Qiangqiang Cai, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4248223/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background To explore the clinical efficacy and safety of Kirschner wires (KWs) as a blocking screw technique for extra-articular fractures of the distal tibia treated with intramedullary nails (IMNs). Methods Fifty-three patients were treated with KW-assisted IMN for extra-articular fractures of the distal tibia via the blocking screw technique or poller screw (PS) technique. The operation time, number of fluoroscopies, number of blocking screws used, blood loss and time to union were compared between the two groups. Additionally, the functional outcomes of the two groups were compared using range of motion (ROM), visual analog scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS), and Lysholm scores. Results Compared with those in the PS group, the operation time in the KW group was significantly shorter, and the number of fluoroscopy procedures and amount of blood loss during KW surgery were also significantly lower ( P = 0.014, 0.001, and 0.036, respectively). Regarding the functional outcomes, there were no significant differences in the ROM, VAS score, AOFAS score or Lysholm score between the two groups ( P > 0.05). Conclusion In the treatment of extra-articular fractures of the distal tibia with nails, the use of KW as a blocking screw technique is safe and reliable. Distal tibial fracture Intramedullary nails Kirschner wires Poller screws Blocking screws Fracture fixation Figures Figure 1 Figure 2 Figure 3 Background Tibial fracture is one of the most common lower limb fractures and is often caused by high-energy injuries such as traffic accidents, falls, direct attacks, and sports injuries[ 1 ]. Treatment options can be roughly divided into conservative treatment and surgical treatment. In general, operative fixation is recommended for patients with open fractures, segmental/severely comminuted fractures or closed injuries in which fracture reduction and tibial alignment cannot be effectively maintained.[ 2 ] The objective of surgical treatment is to correct the angulation, rotation and shortening deformity of the fracture site, achieve bone union of the fracture site, and restore lower limb alignment[ 3 ]. There are various surgical methods for treating extra-articular fractures of the distal tibia, such as open reduction internal fixation, which requires extensive soft tissue dissection and often leads to postoperative complications such as nonunion and infection.[ 4 ] In recent years, with the rapid development of minimally invasive techniques, minimally invasive plate osteosynthesis (MIPO) and intramedullary nail (IMN) fixation have become two prevalent surgical methods for extra-articular distal tibia fractures[ 5 ]. However, a study has shown that treatment of distal tibia extra-articular fractures, MIPO compared with IMN, is associated with a greater risk of incision complications and a longer time to union[ 6 ]. Currently, IMN is the standard treatment for unstable tibial shaft fractures [ 7 – 9 ] However, for fractures of the distal tibia, due to the presence of the epiphysis, where the bone marrow cavity is relatively wide, lateral displacement and/or angulation deformity of the fracture site and significant axial instability of the fracture site often occur during the insertion of the IMN[ 10 ]; when this occurs, the conventional course of action is to artificially narrow the diameter of the medullary cavity of the epiphyseal site by placing blocking screws (poller screws[ 11 ], PS) and creating lateral pushing force to correct the alignment of the fracture site and maintain the stability of the fracture site.[ 12 – 14 ] However, it should be noted that in the process of blocking screw implantation, the steps are complicated, and complications such as bone splitting and blocking screw breakage may occur.[ 14 , 15 ] To the best of our knowledge, no specific studies have reported the application of the KW blocking technique in treating extra-articular fractures of the distal tibia with IMN. The aim of this study was to assess the clinical efficacy and safety of the KW blocking technique in extra-articular fractures of the distal tibia treated with a nail. Patients and methods Patients Patients treated with IMN due to distal tibial fracture in our hospital were selected from January 2018 to March 2021. The inclusion criteria were (1) Age > 18 years at the time of injury. (2) Extra-articular distal tibia fracture (AO/OTA: 43. A1-A3). (3) Use KW as temporary blocking or PS technique to assist fracture site reduction during operation. (4) at least 12 months of follow-up. The exclusion criteria were (1) Open fractures. (2) Operative leg with major vascular or nerve injury. (3) Additional orthopedic injury (other than ipsilateral fibula). (4) Prior fracture with the ipsilateral leg. (5) Surgical history of the operative leg. (6) Have pathological or metabolic bone disease (Fig. 1 ). This study was conducted retrospectively and approved by the Ethics Committee of our hospital. All patients or their authorized relatives signed an informed consent document before receiving a clinical evaluation. The KW group was defined as patients with intraoperative KW-assisted reduction, and the PS group was defined as patients with intraoperative PS-assisted reduction. For the patients included in this study, surgery was performed after the swelling of the injured site went down. The average waiting time for surgery was 4.2 ± 1.4 (range, 2–8) days in the KW group and 4.7 ± 1.6 (range, 2–8) days in the PS group, respectively. All patients in the two groups were followed up for at least 12 months. Methods All patients received intravenous antibiotics of 1 g cefazolin sodium 30 min prior to surgery to prevent infection, and all operations were completed by the same surgical team composed of one senior surgeon and two assistants. After adequate anesthesia, the patients were placed in the supine position. If there was a distal fibula fracture, it was treated with an open reduction plate and screw internal fixation, and then the distal tibia fracture was treated. Conservative treatment was performed for fractures of the middle and upper thirds of the fibula. All patients underwent the infrapatellar approach, and the operation before the insertion of the main nail was described by Lu et al. [ 16 ]. If the IMN (Expert Tibial Nail) was not in the center of the distal tibial medullary cavity after insertion or if the patients had an angular deformity greater than 5° on the coronal plane or 10° on the sagittal plane or obvious lateral displacement at the fracture site, KW, as a temporary blocking or PS technique, was applied to adjust the distal position of the IMN or correct the angular deformity and obvious lateral displacement. For patients in the KW group, the IMN was first withdrawn, and then a KW with a diameter of 2.5 or 3 mm or more was inserted percutaneously at the distal fractures of the tibia, the concave side of the angular deformity, or the acute angle side of the connection between the fracture line and the longitudinal axis of the diaphysis, 1 cm from the fracture line, 0.5 cm in the center of the medullary cavity; finally, the IMN was reinserted. At this time, if the position of the IMN is satisfactory and the angular deformity and lateral displacement of the fracture site are corrected, distal and proximal IMN locking screws are inserted successively, the KW is removed, and the ankle joint is moved to check the stability of the fracture site. Otherwise, the position of the KW was adjusted, and the above steps were repeated. Multiple KWs were placed if necessary until the position of the IMN and the alignment of the fracture site were corrected (Fig. 2 ). For the PS group, the methods were described by Krettek et al. [ 11 ]. First, the IMN was removed, and then suitable blocking screws were inserted percutaneously using the same method used for the KW group; similarly, multiple PSs were placed if necessary until the position of the IMN and the alignment of the fracture site were corrected (Fig. 3 ). All patients received 1 g of cefazolin sodium intravenously again within 24 hours after surgery. Rehabilitation protocol On the first day after surgery, the affected limb began to exercise, such as ankle pump movement and quadriceps isometric contraction. Both active and passive exercises of knee motion were started on the first day after surgery, and it was recommended to flex the knee more than 90˚ at two weeks after surgery. Partial weight-bearing can be started four weeks after surgery, 50% weight-bearing can be carried eight weeks after surgery, and full weight-bearing can be carried three months after surgery generally. Clinical assessment Before discharge, we informed the patients that outpatient follow-up was required 1, 3, 6 and 12 months after the surgery. At each follow-up, radiographs were acquired to evaluate reduction quality and bone union. Data were obtained through the following items in the follow-up of 12 months after the operation: Visual Analog Scale (VAS, 0 = excellent, 10 = Extreme Pain)[ 17 ] was used to evaluate postoperative pain relief, and range of motion (ROM) of knee joint, the American Orthopedic Foot and Ankle Society (AOFAS)[ 18 ] and Lysholm[ 19 ] scores used to assess functional outcomes of the affected limb. Statistical analysis Statistical analysis was performed using SPSS 25.0 (IBM Corp, USA). Continuous variables were expressed as mean ± standard deviation (range), and classification variables were expressed as n (%). Kolmogorov-Smirnov was used to test whether the data were following the normal distribution, in which age and operation time were following the normal distribution data, and the variance was homogeneity, so two independent samples t-test was used. The Mann-Whitney U-test with two independent samples was used for the variables such as the times of fluoroscopy, the amount of blood loss and ROM, which did not conform to the normal distribution or variance. Categorical variables such as gender, cause of injury, and fracture type were tested by the Chi-Square or Fisher's exact test. P < 0.05 was considered statistically significant. Results General data 53 patients were included, including 28 patients in the KW group (12 males and 16 females, with an average age of 39.2 ± 15.3 (range, 19–68) years. In the PS group, there were 25 patients (16 males and 9 females, mean age 43.3 ± 15.2 (range, 19–70) years. There were no statistically significant differences between the two groups in age ( p = 0.333), gender ( p = 0.170), injured left or right legs ( p = 0.785), ipsilateral fibula accompanying fracture ( p = 0.894), time from injury to surgery ( p = 0.199), injury causes ( p = 0.871) and fracture types ( p = 0.801). In addition, a total of 28 patients in the KW group were finally followed up, with an average follow-up time of 19.0 ± 6.0 (range, 12–36) months. A total of 25 patients in the PS group were finally followed up, with an average follow-up time of 21.6 ± 5.9 (range, 12–33) months. There was no significant difference in the average follow-up time between the two groups ( P = 0.063; Table 1 ). Table 1 Patient demographics. KW PS P-value Age 39.2 ± 15.3 (19–68) 43.3 ± 15.2 (19–70) 0.333 a Sex, no. (%) Male Female 12(42.9) 16(57.1) 16(64) 9(36) 0.170 c Side, no. (%) Left Right 14(50) 14(50) 11(44) 14(56) 0.785 c Time to surgery(day) 4.2 ± 1.4 (2–8) 4.7 ± 1.6 (2–8) 0.199 b Cause of injury, no. (%) Traffic Fall Sport other 17(60.7) 6 (21.4) 4(14.3) 1(3.6) 18(72) 5(20) 2(8) 0(0) 0.871 d Ipsilateral fibula fracture, no. (%) Proximal Middle Distal None 6(21.4) 4(14.3) 8(28.6) 10(35.7) 7(28) 4(16) 5(20) 9(36) 0.894 d AO/OTA classification, no. (%) 43-A1 43-A2 43-A3 15(53.6) 8(28.6) 5(17.9) 16(64) 5(20) 4(16) 0.801 c Follow-up(month) 19.0 ± 6.0 (12–36) 21.6 ± 5.9 (12–33) 0.063 b a ttest, b MannWhitney Utest, c Chi-squared test. d Fisher's exact test. Values are expressed as n (%) or the mean ± standard deviation. KW, Kirschner wires, PS, Poller screws Intraoperative comparison The mean operation time of the KW group was significantly shorter than that of the PS group [62.9 ± 10.6 (range, 48–90) min vs 71.8 ± 14.8 (range, 55–120) min, P = 0.014)]. The average times of fluoroscopy of KW were significantly less than that of the PS group [(14.8 ± 1.5 (range, 13–20) vs 17.8 ± 1.5 (range, 16–22), P < 0.001)]. However, there was no significant difference in the numbers of KW and PS [(1.3 ± 0.5 (range, 1–3) vs 1.2 ± 0.4 (range, 1–2), P = 0.288)]. Finally, the blood loss in the KW group was significantly less than that in the PS group [(171.8 ± 55.9 (range, 100–350) ml vs 218.8 ± 82.0 (range, 100–400) ml, P = 0.036; Table 2 ). Table 2 Intraoperative comparison KW PS P-value Operation time(min) 62.9 ± 10.6 (48–90) 71.8 ± 14.8 (55–120) 0.014 a Fluoroscopy times 14.8 ± 1.5 (13–20) 17.8 ± 1.5 (16–22) < 0.001 b Number of blocking screws 1.3 ± 0.5 (1–3) 1.2 ± 0.4 (1–2) 0.288 b Blood loss(ml) 171.8 ± 55.9 (100–350) 218.8 ± 82.0 (100–400) 0.036 b a ttest, b MannWhitney Utest, c Chi-squared test. d Fisher's exact test. Values are expressed as n (%) or the mean ± standard deviation. KW, Kirschner wires; PS, Poller screws Functional outcomes The AOFAS scores of the KW group and PS group were 93.9 ± 6.2 (range, 74–100, excellent) and 90.0 ± 10.5 (range, 55–100, excellent), respectively ( P = 0.182). The Lysholm score of the KW group and PS group was 94.6 ± 5.1 (range, 81–100, good) and 91.4 ± 9.8 (range, 60–100, good), respectively ( P = 0.200). The two groups had no significant difference in AOFAS and Lysholm scores. For VAS and ROM, there was no significant difference between the KW group and PS group [(1.3 ± 1.0 (range, 0–3) vs 1.2 ± 1.1 (range, 0–3) P = 0.711)] and [(0°/141.6° ± 4.7° (range, 130°-145°) vs 0°/137.8° ± 9.0° (range, 110°-145°)] P = 0.114). Finally, the time to union of the KW group was 12.5 ± 1.5 (range, 10–15) weeks, while that of the PS group was 13.6 ± 2.6 (range, 10–22) weeks, the difference was not statistically significant ( P = 0.108; Table 3 ). Table 3 clinical and functional outcomes of the two groups KW PS P-value Fracture healing (weeks) 12.5 ± 1.5 (10–15) 13.6 ± 2.6 (10–22) 0.108 b ROM°(extension/flexion) 0/141.6 ± 4.7 (130–145) 0/137.8 ± 9.0 (110–145) 0.114 b VAS 1.3 ± 1.0 (0–3) 1.2 ± 1.1 (0–3) 0.711 b AOFAS 93.9 ± 6.2 (74–100) 90.0 ± 10.5 (55–100) 0.182 b Lysholm 94.6 ± 5.1 (81–100) 91.4 ± 9.8 (60–100) 0.200 b a ttest, b MannWhitney Utest, c Chi-squared test. d Fisher's exact test. Values are expressed as n (%) or the mean ± standard deviation. KW, Kirschner wires; PS, Poller screws; ROM, range of motion; VAS, visual analogue scale; AOFAS, American Orthopaedic Foot and Ankle Society; Lysholm, Lysholm Knee Function Score. Complications In the KW group, one patient developed a superficial soft tissue infection at the distal locking screws of the IMN, which was cured after daily dressing change and appropriate antibiotic treatment. In the PS group, one case of new fracture and one case of screw breakage. The other patient had nonunion (Table 4 ). Discussion Due to the unique advantages of IMN in the treatment of long shaft fractures of limbs, such as avoiding the dissection of soft tissues around the fracture site and the destruction of the periosteum by closed reduction and protecting the blood supply of the fracture site to a great extent, it is highly conducive to promoting bone union and reducing the incidence of infection[ 7 , 20 , 21 ]. In addition, several small incisions can be made in IMNs through minimally invasive methods; generally, the maximum incision length is less than 4 cm, and IMNs are widely prevalent among patients.[ 22 , 23 ] However, in the treatment of distal tibial fractures with IMN, the blocking screw technique is often used by placing blocking screws at an appropriate position at the fracture site to correct the malalignment of the fracture site and the distal position of the nail[ 24 ]; then, three-point fixation occurs at the isthmus of the long bone, the screws, and the anchorage point at the tip of the nail.[ 25 , 26 ] However, in clinical practice, the placement of blocking screws requires drilling, length measurement and screw insertion, which are cumbersome. When adjusting the position of the blocking screws, the need for repeated fluoroscopy is inevitable, which increases the radiation exposure of patients and prolongs the operation time. The KW blocking technique is derived from blocking screw logic.[ 27 ] In this study, we compared the clinical efficacy and safety of the KW blocking technique with those of the Poller screw technique for the treatment of extra-articular fractures of the distal tibia with nails. The average operation time of the KW group was significantly shorter than that of the PS group, and the amount of blood loss and number of fluoroscopy procedures were significantly lower. However, the functional outcomes of patients in the two groups were similar, preliminarily demonstrating the safety and reliability of the KW technique for temporary blocking. In addition, no obvious malunion or hardware failure occurred in the two study groups. The possible reasons for this observation are as follows. First, after successively inserting the distal and proximal IMN locking screws, the stability of the fracture site was routinely examined by moving the ankle joint. If the stability was insufficient, the number of distal locking screws of the IMN or blocking screws was increased simultaneously or separately (patients in the KW group were assigned to the PS group if they were eventually treated with blocking screws due to poor stability) to ensure that the stability of the fracture site was reliable. However, in clinical practice, such cases are rare. Second, at discharge, we routinely informed patients that they should undergo outpatient review before full weight bearing of the affected leg, which is allowed when an adequate bridging callus is visible on radiographs. Third, all surgeries were performed by a senior doctor in our hospital, and the quality of surgery was guaranteed. According to our study, the KW blocking technique has the following advantages compared with the blocking screw technique. First, the KW placement procedure is simple and can reduce the operation time and radiation exposure for patients[ 28 ]. Second, after the distal and proximal locking screws of the IMN were locked successfully, the KW could be removed to avoid the potential risk of skin and subcutaneous soft tissue irritation caused by the indwelling of the blocking screws, and no secondary surgical removal was needed. Third, KW has excellent toughness, and even if it experiences bending deformation during operation, it is difficult to break. Fourth, KW has different diameters, which can be selected according to the specific situation. KW is a conventional standby instrument in the orthopedic operating room that can be easily obtained. In addition, with the advent of the Expert Tibia Nail (ETN) [ 22 ], in the proximal part, there are five locking options in four planes, and at the distal site, there are four locking options in three planes, with the most distal hole situated 5 mm proximal to the nail tip, which allows the surgeon to achieve improved fixation and angle stable locking. Hence, three-point fixation of the fracture site can be achieved without the need for blocking screws to maintain stability between the fracture sites until bone union is achieved. This study has several limitations. First, this study was conducted retrospectively, and high-quality randomized controlled trials are needed. Second, the relatively small sample size of this study may limit the generalizability of the results, and larger sample size studies may be needed in the future to confirm the findings. Third, the study only explored the KW blocking technique in extra-articular fractures of the distal tibia; when this technique is applied to other parts of the limb long bone, its functional outcomes need to be further explored. Conclusion The KW blocking technique is safe and reliable for treating extra-articular fractures of the distal tibia with IMN. Compared with PS, the KW blocking technique not only significantly shortened the operation time but also significantly reduced the amount of blood loss and number of fluoroscopy procedures. Abbreviations KW: Kirschner wires; PS: Poller screws; ROM: range of motion; VAS: visual analogue Scale (VAS); AOFAS: American Orthopaedic Foot and Ankle Society; MIPO: Minimally invasive plate osteosynthesis; IMN: intramedullary nail; AO/OTA: the AO Foundation/Orthopaedic Trauma Association; ETN: the Expert Tibia Nail. Declarations Ethics approval and consent to participate The present study was approved by our hospital All patients or their relatives provided informed consent prior to participation in the study. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors’ contributions XF contributed to the study conception and design. data collection was performed by LL, SD and HK. LY, QC, ZS, WW, ZM and WT performed the analysis. The first draft of the manuscript was written by JL. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Hiesterman TG, Shafiq BX, Cole PA: Intramedullary nailing of extra-articular proximal tibia fractures. J Am Acad Orthop Surg 2011, 19(11):690-700. Wood GW, 2nd: Intramedullary nailing of femoral and tibial shaft fractures. J Orthop Sci 2006, 11(6):657-669. Teulières M, Langlais T, de Gauzy JS, Rölfing JD, Accadbled F: Bone Lengthening with a Motorized Intramedullary Nail in 34 Patients with Posttraumatic Limb Length Discrepancies. J Clin Med 2021, 10(11). Piątkowski K, Piekarczyk P, Kwiatkowski K, Przybycień M, Chwedczuk B: Comparison of different locking plate fixation methods in distal tibia fractures. Int Orthop 2015, 39(11):2245-2251. 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Zhang CM, Sun L, Wang Q, Huang Q, Lin H, Duan N et al : A New Technique for Placement of Blocking Screws and its Mechanical Effect on Stability of Tibia Fractures with Distal Fragments after Insertion of Small-Diameter Intramedullary Nails. Orthop Surg 2021, 13(7):2127-2136. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4248223","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":290515771,"identity":"256750d9-5e23-4da8-9a68-e58fba7442a3","order_by":0,"name":"Jun Liu","email":"","orcid":"","institution":"The Third Hospital of Nanchang","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Liu","suffix":""},{"id":290515772,"identity":"f7176509-4264-40f1-bd6d-8b2b1c7b4df2","order_by":1,"name":"Simin Dai","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Simin","middleName":"","lastName":"Dai","suffix":""},{"id":290515774,"identity":"b8af320e-1806-43f4-9c68-424a49f75a00","order_by":2,"name":"Lijin Liu","email":"","orcid":"","institution":"The Third Hospital of Nanchang","correspondingAuthor":false,"prefix":"","firstName":"Lijin","middleName":"","lastName":"Liu","suffix":""},{"id":290515777,"identity":"440dd531-753e-421a-81e4-05466c9aeddc","order_by":3,"name":"Hailin Kuang","email":"","orcid":"","institution":"The Third Hospital of Nanchang","correspondingAuthor":false,"prefix":"","firstName":"Hailin","middleName":"","lastName":"Kuang","suffix":""},{"id":290515780,"identity":"0754a390-8866-444f-a162-fc6e489e3ef8","order_by":4,"name":"Liang Yan","email":"","orcid":"","institution":"The Third Hospital of Nanchang","correspondingAuthor":false,"prefix":"","firstName":"Liang","middleName":"","lastName":"Yan","suffix":""},{"id":290515783,"identity":"52ea9b9a-9f26-4a6b-926b-1d14d5580d70","order_by":5,"name":"Qiangqiang Cai","email":"","orcid":"","institution":"The Third Hospital of Nanchang","correspondingAuthor":false,"prefix":"","firstName":"Qiangqiang","middleName":"","lastName":"Cai","suffix":""},{"id":290515786,"identity":"5f2fc642-6bc5-44eb-8753-0d5453927eea","order_by":6,"name":"Zongzuan Shao","email":"","orcid":"","institution":"The Third Hospital of Nanchang","correspondingAuthor":false,"prefix":"","firstName":"Zongzuan","middleName":"","lastName":"Shao","suffix":""},{"id":290515789,"identity":"2592ee18-799d-4787-a0d2-3dcf7974a011","order_by":7,"name":"Wenbo Wei","email":"","orcid":"","institution":"The Third Hospital of Nanchang","correspondingAuthor":false,"prefix":"","firstName":"Wenbo","middleName":"","lastName":"Wei","suffix":""},{"id":290515791,"identity":"d8b7b3ac-57b9-4024-91d3-5bdfb9c81dc3","order_by":8,"name":"Zhihai Min","email":"","orcid":"","institution":"The Third Hospital of Nanchang","correspondingAuthor":false,"prefix":"","firstName":"Zhihai","middleName":"","lastName":"Min","suffix":""},{"id":290515793,"identity":"553c0074-e101-4965-b5c7-4e0a02c81a52","order_by":9,"name":"Wubing Tang","email":"","orcid":"","institution":"The Third Hospital of Nanchang","correspondingAuthor":false,"prefix":"","firstName":"Wubing","middleName":"","lastName":"Tang","suffix":""},{"id":290515795,"identity":"157c2186-f645-44de-9129-91424e64564e","order_by":10,"name":"Xiaoxing Fu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIie3PsWrDMBCAYRmDs1zQKlM/hEqGEDDxq8gYPPkBMp4xeOoDqGNfovMJDVlKvQaytEu7dLC3LC01gbRTZY+B6l+k4T5OYsznu8IWyBiNJzAW1C/5Vwqco5sA/ZCwkX1UJrGmaXJZ2MY6sqlENUFEdUunnU3W/AFvADqQjIJ+qFykVObuqYSNfsUViCOsQwzj+8e/SSYKomWbgjwYLEAeYYMUhUsHAZGj+WzFmVhQzyBJTZGC7HlLV9e1JppB4E3ZZPyLPAQNG8a3xdo0zr/AoloNHzubyW7/fspxm3HemH5wkN+EutwCnDM/xmnmoM/n8/27vgFPblaaizgTJgAAAABJRU5ErkJggg==","orcid":"","institution":"The Third Hospital of Nanchang","correspondingAuthor":true,"prefix":"","firstName":"Xiaoxing","middleName":"","lastName":"Fu","suffix":""}],"badges":[],"createdAt":"2024-04-10 15:32:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4248223/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4248223/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55003520,"identity":"0111417c-5284-4f96-9811-2877fbfed4f4","added_by":"auto","created_at":"2024-04-19 18:42:34","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":456710,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe flowchart for patient selection.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4248223/v1/54a1f9ddb1020025d24b8eb5.jpg"},{"id":55003517,"identity":"eeb878b9-18eb-4d22-9e46-6bf69f4bba57","added_by":"auto","created_at":"2024-04-19 18:42:34","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1814460,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKirschner wires blocking technique in a 49-year-old female patient treated with nailing. \u003c/strong\u003eA and B Pre-operative anteroposterior and lateral view. C A Kirschner wire was placed for temporary blocking. D With the assistance of Kirschner wire, the nail was inserted accurately. E Final nail position, distal locking. F Kirschner wire was removed at the end of the procedure. G and H Post-operative anteroposterior and lateral view.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4248223/v1/c43ef9622679284740f8e16d.jpg"},{"id":55003519,"identity":"502c1ee9-728d-489d-bf9f-4748b9f70e6c","added_by":"auto","created_at":"2024-04-19 18:42:34","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1453566,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePoller screws technique in a 48-year-old male patient treated with nailing.\u003c/strong\u003e A and B Pre-operative anteroposterior and lateral view. C location. D A Poller screws was placed and guidewire inserted. E Nail inserted. F distal locking. G and H Post-operative anteroposterior and lateral view.\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4248223/v1/33e97ff3afe6ea3ae4d267a6.jpg"},{"id":55264421,"identity":"5b2dd3f8-c26c-4ada-bf9c-2aa1674e8b18","added_by":"auto","created_at":"2024-04-25 01:42:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":900837,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4248223/v1/2f1a1565-a8c9-4f87-8a5e-a2ad03ada9be.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Kirschner wires as blocking screws in extra-articular fractures of the distal tibia treated with intramedullary nail","fulltext":[{"header":"Background","content":"\u003cp\u003eTibial fracture is one of the most common lower limb fractures and is often caused by high-energy injuries such as traffic accidents, falls, direct attacks, and sports injuries[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Treatment options can be roughly divided into conservative treatment and surgical treatment. In general, operative fixation is recommended for patients with open fractures, segmental/severely comminuted fractures or closed injuries in which fracture reduction and tibial alignment cannot be effectively maintained.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] The objective of surgical treatment is to correct the angulation, rotation and shortening deformity of the fracture site, achieve bone union of the fracture site, and restore lower limb alignment[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. There are various surgical methods for treating extra-articular fractures of the distal tibia, such as open reduction internal fixation, which requires extensive soft tissue dissection and often leads to postoperative complications such as nonunion and infection.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] In recent years, with the rapid development of minimally invasive techniques, minimally invasive plate osteosynthesis (MIPO) and intramedullary nail (IMN) fixation have become two prevalent surgical methods for extra-articular distal tibia fractures[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, a study has shown that treatment of distal tibia extra-articular fractures, MIPO compared with IMN, is associated with a greater risk of incision complications and a longer time to union[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Currently, IMN is the standard treatment for unstable tibial shaft fractures [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHowever, for fractures of the distal tibia, due to the presence of the epiphysis, where the bone marrow cavity is relatively wide, lateral displacement and/or angulation deformity of the fracture site and significant axial instability of the fracture site often occur during the insertion of the IMN[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]; when this occurs, the conventional course of action is to artificially narrow the diameter of the medullary cavity of the epiphyseal site by placing blocking screws (poller screws[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], PS) and creating lateral pushing force to correct the alignment of the fracture site and maintain the stability of the fracture site.[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] However, it should be noted that in the process of blocking screw implantation, the steps are complicated, and complications such as bone splitting and blocking screw breakage may occur.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] To the best of our knowledge, no specific studies have reported the application of the KW blocking technique in treating extra-articular fractures of the distal tibia with IMN.\u003c/p\u003e \u003cp\u003eThe aim of this study was to assess the clinical efficacy and safety of the KW blocking technique in extra-articular fractures of the distal tibia treated with a nail.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003ePatients treated with IMN due to distal tibial fracture in our hospital were selected from January 2018 to March 2021. The inclusion criteria were (1) Age\u0026thinsp;\u0026gt;\u0026thinsp;18 years at the time of injury. (2) Extra-articular distal tibia fracture (AO/OTA: 43. A1-A3). (3) Use KW as temporary blocking or PS technique to assist fracture site reduction during operation. (4) at least 12 months of follow-up. The exclusion criteria were (1) Open fractures. (2) Operative leg with major vascular or nerve injury. (3) Additional orthopedic injury (other than ipsilateral fibula). (4) Prior fracture with the ipsilateral leg. (5) Surgical history of the operative leg. (6) Have pathological or metabolic bone disease (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e This study was conducted retrospectively and approved by the Ethics Committee of our hospital. All patients or their authorized relatives signed an informed consent document before receiving a clinical evaluation. The KW group was defined as patients with intraoperative KW-assisted reduction, and the PS group was defined as patients with intraoperative PS-assisted reduction. For the patients included in this study, surgery was performed after the swelling of the injured site went down. The average waiting time for surgery was 4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 (range, 2\u0026ndash;8) days in the KW group and 4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 (range, 2\u0026ndash;8) days in the PS group, respectively. All patients in the two groups were followed up for at least 12 months.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAll patients received intravenous antibiotics of 1 g cefazolin sodium 30 min prior to surgery to prevent infection, and all operations were completed by the same surgical team composed of one senior surgeon and two assistants. After adequate anesthesia, the patients were placed in the supine position. If there was a distal fibula fracture, it was treated with an open reduction plate and screw internal fixation, and then the distal tibia fracture was treated. Conservative treatment was performed for fractures of the middle and upper thirds of the fibula.\u003c/p\u003e \u003cp\u003eAll patients underwent the infrapatellar approach, and the operation before the insertion of the main nail was described by Lu et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. If the IMN (Expert Tibial Nail) was not in the center of the distal tibial medullary cavity after insertion or if the patients had an angular deformity greater than 5\u0026deg; on the coronal plane or 10\u0026deg; on the sagittal plane or obvious lateral displacement at the fracture site, KW, as a temporary blocking or PS technique, was applied to adjust the distal position of the IMN or correct the angular deformity and obvious lateral displacement. For patients in the KW group, the IMN was first withdrawn, and then a KW with a diameter of 2.5 or 3 mm or more was inserted percutaneously at the distal fractures of the tibia, the concave side of the angular deformity, or the acute angle side of the connection between the fracture line and the longitudinal axis of the diaphysis, 1 cm from the fracture line, 0.5 cm in the center of the medullary cavity; finally, the IMN was reinserted. At this time, if the position of the IMN is satisfactory and the angular deformity and lateral displacement of the fracture site are corrected, distal and proximal IMN locking screws are inserted successively, the KW is removed, and the ankle joint is moved to check the stability of the fracture site. Otherwise, the position of the KW was adjusted, and the above steps were repeated. Multiple KWs were placed if necessary until the position of the IMN and the alignment of the fracture site were corrected (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For the PS group, the methods were described by Krettek et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. First, the IMN was removed, and then suitable blocking screws were inserted percutaneously using the same method used for the KW group; similarly, multiple PSs were placed if necessary until the position of the IMN and the alignment of the fracture site were corrected (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). All patients received 1 g of cefazolin sodium intravenously again within 24 hours after surgery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eRehabilitation protocol\u003c/h2\u003e \u003cp\u003eOn the first day after surgery, the affected limb began to exercise, such as ankle pump movement and quadriceps isometric contraction. Both active and passive exercises of knee motion were started on the first day after surgery, and it was recommended to flex the knee more than 90˚ at two weeks after surgery. Partial weight-bearing can be started four weeks after surgery, 50% weight-bearing can be carried eight weeks after surgery, and full weight-bearing can be carried three months after surgery generally.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eClinical assessment\u003c/h2\u003e \u003cp\u003eBefore discharge, we informed the patients that outpatient follow-up was required 1, 3, 6 and 12 months after the surgery. At each follow-up, radiographs were acquired to evaluate reduction quality and bone union. Data were obtained through the following items in the follow-up of 12 months after the operation: Visual Analog Scale (VAS, 0\u0026thinsp;=\u0026thinsp;excellent, 10\u0026thinsp;=\u0026thinsp;Extreme Pain)[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] was used to evaluate postoperative pain relief, and range of motion (ROM) of knee joint, the American Orthopedic Foot and Ankle Society (AOFAS)[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and Lysholm[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] scores used to assess functional outcomes of the affected limb.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using SPSS 25.0 (IBM Corp, USA). Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (range), and classification variables were expressed as n (%). Kolmogorov-Smirnov was used to test whether the data were following the normal distribution, in which age and operation time were following the normal distribution data, and the variance was homogeneity, so two independent samples t-test was used. The Mann-Whitney U-test with two independent samples was used for the variables such as the times of fluoroscopy, the amount of blood loss and ROM, which did not conform to the normal distribution or variance. Categorical variables such as gender, cause of injury, and fracture type were tested by the Chi-Square or Fisher's exact test. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eGeneral data\u003c/h2\u003e \u003cp\u003e53 patients were included, including 28 patients in the KW group (12 males and 16 females, with an average age of 39.2\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3 (range, 19\u0026ndash;68) years. In the PS group, there were 25 patients (16 males and 9 females, mean age 43.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2 (range, 19\u0026ndash;70) years. There were no statistically significant differences between the two groups in age (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.333), gender (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.170), injured left or right legs (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.785), ipsilateral fibula accompanying fracture (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.894), time from injury to surgery (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.199), injury causes (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.871) and fracture types (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.801). In addition, a total of 28 patients in the KW group were finally followed up, with an average follow-up time of 19.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0 (range, 12\u0026ndash;36) months. A total of 25 patients in the PS group were finally followed up, with an average follow-up time of 21.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9 (range, 12\u0026ndash;33) months. There was no significant difference in the average follow-up time between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.063; Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient demographics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKW\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e39.2\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3 (19\u0026ndash;68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e43.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2 (19\u0026ndash;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.333\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, no. (%)\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(42.9)\u003c/p\u003e \u003cp\u003e16(57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(64)\u003c/p\u003e \u003cp\u003e9(36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.170\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide, no. (%)\u003c/p\u003e \u003cp\u003eLeft\u003c/p\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(50)\u003c/p\u003e \u003cp\u003e14(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(44)\u003c/p\u003e \u003cp\u003e14(56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.785\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to surgery(day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 (2\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 (2\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.199\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCause of injury,\u003c/p\u003e \u003cp\u003eno. (%)\u003c/p\u003e \u003cp\u003eTraffic\u003c/p\u003e \u003cp\u003eFall\u003c/p\u003e \u003cp\u003eSport\u003c/p\u003e \u003cp\u003eother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(60.7)\u003c/p\u003e \u003cp\u003e6 (21.4)\u003c/p\u003e \u003cp\u003e4(14.3)\u003c/p\u003e \u003cp\u003e1(3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(72)\u003c/p\u003e \u003cp\u003e5(20)\u003c/p\u003e \u003cp\u003e2(8)\u003c/p\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.871\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIpsilateral fibula fracture, no. (%)\u003c/p\u003e \u003cp\u003eProximal\u003c/p\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003cp\u003eDistal\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(21.4)\u003c/p\u003e \u003cp\u003e4(14.3)\u003c/p\u003e \u003cp\u003e8(28.6)\u003c/p\u003e \u003cp\u003e10(35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(28)\u003c/p\u003e \u003cp\u003e4(16)\u003c/p\u003e \u003cp\u003e5(20)\u003c/p\u003e \u003cp\u003e9(36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.894\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAO/OTA classification, no. (%)\u003c/p\u003e \u003cp\u003e43-A1\u003c/p\u003e \u003cp\u003e43-A2\u003c/p\u003e \u003cp\u003e43-A3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(53.6)\u003c/p\u003e \u003cp\u003e8(28.6)\u003c/p\u003e \u003cp\u003e5(17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(64)\u003c/p\u003e \u003cp\u003e5(20)\u003c/p\u003e \u003cp\u003e4(16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.801\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up(month)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e19.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0 (12\u0026ndash;36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e21.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9 (12\u0026ndash;33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.063\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e ttest, \u003csup\u003eb\u003c/sup\u003eMannWhitney Utest, \u003csup\u003ec\u003c/sup\u003eChi-squared test. \u003csup\u003ed\u003c/sup\u003eFisher's exact test. Values are expressed as n (%) or the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. KW, Kirschner wires, PS, Poller screws\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eIntraoperative comparison\u003c/h2\u003e \u003cp\u003eThe mean operation time of the KW group was significantly shorter than that of the PS group [62.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6 (range, 48\u0026ndash;90) min vs 71.8\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8 (range, 55\u0026ndash;120) min, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.014)]. The average times of fluoroscopy of KW were significantly less than that of the PS group [(14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 (range, 13\u0026ndash;20) vs 17.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 (range, 16\u0026ndash;22), \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001)]. However, there was no significant difference in the numbers of KW and PS [(1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 (range, 1\u0026ndash;3) vs 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 (range, 1\u0026ndash;2), \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.288)]. Finally, the blood loss in the KW group was significantly less than that in the PS group [(171.8\u0026thinsp;\u0026plusmn;\u0026thinsp;55.9 (range, 100\u0026ndash;350) ml vs 218.8\u0026thinsp;\u0026plusmn;\u0026thinsp;82.0 (range, 100\u0026ndash;400) ml, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative comparison\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKW\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time(min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e62.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6 (48\u0026ndash;90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e71.8\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8 (55\u0026ndash;120)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.014\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFluoroscopy times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 (13\u0026ndash;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e17.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 (16\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of blocking screws\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 (1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.288\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss(ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e171.8\u0026thinsp;\u0026plusmn;\u0026thinsp;55.9 (100\u0026ndash;350)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e218.8\u0026thinsp;\u0026plusmn;\u0026thinsp;82.0 (100\u0026ndash;400)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.036\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e ttest, \u003csup\u003eb\u003c/sup\u003eMannWhitney Utest, \u003csup\u003ec\u003c/sup\u003eChi-squared test. \u003csup\u003ed\u003c/sup\u003eFisher's exact test. Values are expressed as n (%) or the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. KW, Kirschner wires; PS, Poller screws\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFunctional outcomes\u003c/h2\u003e \u003cp\u003eThe AOFAS scores of the KW group and PS group were 93.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2 (range, 74\u0026ndash;100, excellent) and 90.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 (range, 55\u0026ndash;100, excellent), respectively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.182). The Lysholm score of the KW group and PS group was 94.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1 (range, 81\u0026ndash;100, good) and 91.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8 (range, 60\u0026ndash;100, good), respectively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.200). The two groups had no significant difference in AOFAS and Lysholm scores. For VAS and ROM, there was no significant difference between the KW group and PS group [(1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 (range, 0\u0026ndash;3) vs 1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 (range, 0\u0026ndash;3) \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.711)] and [(0\u0026deg;/141.6\u0026deg; \u0026plusmn; 4.7\u0026deg; (range, 130\u0026deg;-145\u0026deg;) vs 0\u0026deg;/137.8\u0026deg; \u0026plusmn; 9.0\u0026deg; (range, 110\u0026deg;-145\u0026deg;)] \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.114). Finally, the time to union of the KW group was 12.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 (range, 10\u0026ndash;15) weeks, while that of the PS group was 13.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 (range, 10\u0026ndash;22) weeks, the difference was not statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.108; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eclinical and functional outcomes of the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKW\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture healing (weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e12.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 (10\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e13.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6 (10\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.108\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eROM\u0026deg;(extension/flexion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0/141.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 (130\u0026ndash;145)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0/137.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0 (110\u0026ndash;145)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.114\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 (0\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 (0\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.711\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAOFAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e93.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2 (74\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e90.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 (55\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.182\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLysholm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e94.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1 (81\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e91.4\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8 (60\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.200\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003ettest, \u003csup\u003eb\u003c/sup\u003eMannWhitney Utest, \u003csup\u003ec\u003c/sup\u003eChi-squared test. \u003csup\u003ed\u003c/sup\u003eFisher's exact test. Values are expressed as n (%) or the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. KW, Kirschner wires; PS, Poller screws; ROM, range of motion; VAS, visual analogue scale; AOFAS, American Orthopaedic Foot and Ankle Society; Lysholm, Lysholm Knee Function Score.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eComplications\u003c/h2\u003e \u003cp\u003eIn the KW group, one patient developed a superficial soft tissue infection at the distal locking screws of the IMN, which was cured after daily dressing change and appropriate antibiotic treatment. In the PS group, one case of new fracture and one case of screw breakage. The other patient had nonunion (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e\u003cimg 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\" style=\"width: 635px; height: 347.703px;\" width=\"635\" height=\"347.703\"\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDue to the unique advantages of IMN in the treatment of long shaft fractures of limbs, such as avoiding the dissection of soft tissues around the fracture site and the destruction of the periosteum by closed reduction and protecting the blood supply of the fracture site to a great extent, it is highly conducive to promoting bone union and reducing the incidence of infection[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In addition, several small incisions can be made in IMNs through minimally invasive methods; generally, the maximum incision length is less than 4 cm, and IMNs are widely prevalent among patients.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHowever, in the treatment of distal tibial fractures with IMN, the blocking screw technique is often used by placing blocking screws at an appropriate position at the fracture site to correct the malalignment of the fracture site and the distal position of the nail[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]; then, three-point fixation occurs at the isthmus of the long bone, the screws, and the anchorage point at the tip of the nail.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHowever, in clinical practice, the placement of blocking screws requires drilling, length measurement and screw insertion, which are cumbersome. When adjusting the position of the blocking screws, the need for repeated fluoroscopy is inevitable, which increases the radiation exposure of patients and prolongs the operation time. The KW blocking technique is derived from blocking screw logic.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn this study, we compared the clinical efficacy and safety of the KW blocking technique with those of the Poller screw technique for the treatment of extra-articular fractures of the distal tibia with nails. The average operation time of the KW group was significantly shorter than that of the PS group, and the amount of blood loss and number of fluoroscopy procedures were significantly lower. However, the functional outcomes of patients in the two groups were similar, preliminarily demonstrating the safety and reliability of the KW technique for temporary blocking. In addition, no obvious malunion or hardware failure occurred in the two study groups. The possible reasons for this observation are as follows. First, after successively inserting the distal and proximal IMN locking screws, the stability of the fracture site was routinely examined by moving the ankle joint. If the stability was insufficient, the number of distal locking screws of the IMN or blocking screws was increased simultaneously or separately (patients in the KW group were assigned to the PS group if they were eventually treated with blocking screws due to poor stability) to ensure that the stability of the fracture site was reliable. However, in clinical practice, such cases are rare. Second, at discharge, we routinely informed patients that they should undergo outpatient review before full weight bearing of the affected leg, which is allowed when an adequate bridging callus is visible on radiographs. Third, all surgeries were performed by a senior doctor in our hospital, and the quality of surgery was guaranteed.\u003c/p\u003e \u003cp\u003eAccording to our study, the KW blocking technique has the following advantages compared with the blocking screw technique. First, the KW placement procedure is simple and can reduce the operation time and radiation exposure for patients[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Second, after the distal and proximal locking screws of the IMN were locked successfully, the KW could be removed to avoid the potential risk of skin and subcutaneous soft tissue irritation caused by the indwelling of the blocking screws, and no secondary surgical removal was needed. Third, KW has excellent toughness, and even if it experiences bending deformation during operation, it is difficult to break. Fourth, KW has different diameters, which can be selected according to the specific situation. KW is a conventional standby instrument in the orthopedic operating room that can be easily obtained. In addition, with the advent of the Expert Tibia Nail (ETN) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], in the proximal part, there are five locking options in four planes, and at the distal site, there are four locking options in three planes, with the most distal hole situated 5 mm proximal to the nail tip, which allows the surgeon to achieve improved fixation and angle stable locking. Hence, three-point fixation of the fracture site can be achieved without the need for blocking screws to maintain stability between the fracture sites until bone union is achieved.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, this study was conducted retrospectively, and high-quality randomized controlled trials are needed. Second, the relatively small sample size of this study may limit the generalizability of the results, and larger sample size studies may be needed in the future to confirm the findings. Third, the study only explored the KW blocking technique in extra-articular fractures of the distal tibia; when this technique is applied to other parts of the limb long bone, its functional outcomes need to be further explored.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe KW blocking technique is safe and reliable for treating extra-articular fractures of the distal tibia with IMN. Compared with PS, the KW blocking technique not only significantly shortened the operation time but also significantly reduced the amount of blood loss and number of fluoroscopy procedures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eKW: Kirschner wires; PS: Poller screws; ROM: range of motion; VAS: visual analogue Scale (VAS); AOFAS: American Orthopaedic Foot and Ankle Society; MIPO: Minimally invasive plate osteosynthesis; IMN: intramedullary nail; AO/OTA: the AO Foundation/Orthopaedic Trauma Association; ETN: the Expert Tibia Nail.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study was approved by our hospital All patients or their relatives provided informed consent prior to participation in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXF contributed to the study conception and design. data collection was performed by LL, SD and HK.\u0026nbsp;LY,\u0026nbsp;QC, ZS, WW, ZM and WT\u0026nbsp;performed the analysis. The first draft of the manuscript was written by\u0026nbsp;JL. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHiesterman TG, Shafiq BX, Cole PA: Intramedullary nailing of extra-articular proximal tibia fractures. J Am Acad Orthop Surg 2011, 19(11):690-700.\u003c/li\u003e\n\u003cli\u003eWood GW, 2nd: Intramedullary nailing of femoral and tibial shaft fractures. J Orthop Sci 2006, 11(6):657-669.\u003c/li\u003e\n\u003cli\u003eTeuli\u0026egrave;res M, Langlais T, de Gauzy JS, R\u0026ouml;lfing JD, Accadbled F: Bone Lengthening with a Motorized Intramedullary Nail in 34 Patients with Posttraumatic Limb Length Discrepancies. J Clin Med 2021, 10(11).\u003c/li\u003e\n\u003cli\u003ePiątkowski K, Piekarczyk P, Kwiatkowski K, Przybycień M, Chwedczuk B: Comparison of different locking plate fixation methods in distal tibia fractures. Int Orthop 2015, 39(11):2245-2251.\u003c/li\u003e\n\u003cli\u003eHorn C, D\u0026ouml;bele S, Vester H, Sch\u0026auml;ffler A, Lucke M, St\u0026ouml;ckle U: Combination of interfragmentary screws and locking plates in distal meta-diaphyseal fractures of the tibia: a retrospective, single-centre pilot study. Injury 2011, 42(10):1031-1037.\u003c/li\u003e\n\u003cli\u003eWang B, Zhao Y, Wang Q, Hu B, Sun L, Ren C\u003cem\u003e et al\u003c/em\u003e: Minimally invasive percutaneous plate osteosynthesis versus intramedullary nail fixation for distal tibial fractures: a systematic review and meta-analysis. J Orthop Surg Res 2019, 14(1):456.\u003c/li\u003e\n\u003cli\u003eMaslow JI, Joseph HL, Hong DY, Henry AL, Mitchell PM, Collinge CA: Radiographic Evaluation of the Tibial Intramedullary Nail Entry Point. J Am Acad Orthop Surg 2020, 28(18):e810-e814.\u003c/li\u003e\n\u003cli\u003eRicci WM, O\u0026apos;Boyle M, Borrelli J, Bellabarba C, Sanders R: Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma 2001, 15(4):264-270.\u003c/li\u003e\n\u003cli\u003eLee C, Brodke DJ, Stefanski JT, Gurbani A: Staying Out of Trouble With Intramedullary Nailing of Distal Tibia Fractures. J Am Acad Orthop Surg 2021, 29(2):e62-e71.\u003c/li\u003e\n\u003cli\u003eYakkanti R, Kitchen J, Voor M, Nyland J, Hartley B: Optimal blocking screw placement for retrograde IM nail fixation of distal femur fracture: a standardized biomechanical study of \u0026quot;osteoporotic\u0026quot; synthetic bone. Arch Orthop Trauma Surg 2022, 142(12):3827-3835.\u003c/li\u003e\n\u003cli\u003eKrettek C, Stephan C, Schandelmaier P, Richter M, Pape HC, Miclau T: The use of Poller screws as blocking screws in stabilising tibial fractures treated with small diameter intramedullary nails. J Bone Joint Surg Br 1999, 81(6):963-968.\u003c/li\u003e\n\u003cli\u003eHannah A, Aboelmagd T, Yip G, Hull P: A novel technique for accurate Poller (blocking) screw placement. Injury 2014, 45(6):1011-1014.\u003c/li\u003e\n\u003cli\u003eZelle BA, Boni G: Safe surgical technique: intramedullary nail fixation of tibial shaft fractures. Patient Saf Surg 2015, 9:40.\u003c/li\u003e\n\u003cli\u003eFawdington RA, Lotfi N, Beaven A, Fenton P: Does the Use of Blocking Screws Improve Radiological Outcomes Following Intramedullary Nailing of Distal Tibia Fractures? Strategies Trauma Limb Reconstr 2019, 14(1):11-14.\u003c/li\u003e\n\u003cli\u003eKrettek C, Miclau T, Schandelmaier P, Stephan C, M\u0026ouml;hlmann U, Tscherne H: The mechanical effect of blocking screws (\u0026quot;Poller screws\u0026quot;) in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter intramedullary nails. J Orthop Trauma 1999, 13(8):550-553.\u003c/li\u003e\n\u003cli\u003eLu Y, Wang G, Hu B, Ren C, Sun L, Wang Z\u003cem\u003e et al\u003c/em\u003e: Comparison of suprapatellar versus infrapatellar approaches of intramedullary nailing for distal tibia fractures. J Orthop Surg Res 2020, 15(1):422.\u003c/li\u003e\n\u003cli\u003eCastrej\u0026oacute;n I, Chua JR, Pincus T: A RheuMetric physician checklist to quantitate levels of inflammation, damage and distress on 0-10 visual analogue scales. 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Orthop Surg 2009, 1(4):264-268.\u003c/li\u003e\n\u003cli\u003eStenquist DS, McCaskey M, Diaz M, Munassi SD, Ayala G, Donohue D, Mir HR: Do Long-Segment Blocking Screws Increase the Stability of Intramedullary Nail Fixation in Proximal Tibia Fractures, Eliminating the \u0026quot;Bell-Clapper Effect?\u0026quot;. J Orthop Trauma 2024, 38(1):e4-e8.\u003c/li\u003e\n\u003cli\u003eNguyen Van L, Le Van D: Complications and functional, psychological outcomes of bilateral tibial lengthening over intramedullary nail: evidence from Vietnam. Int Orthop 2021, 45(8):2007-2015.\u003c/li\u003e\n\u003cli\u003eStedtfeld HW, Mittlmeier T, Landgraf P, Ewert A: The logic and clinical applications of blocking screws. J Bone Joint Surg Am 2004, 86-A Suppl 2:17-25.\u003c/li\u003e\n\u003cli\u003eZhang CM, Sun L, Wang Q, Huang Q, Lin H, Duan N\u003cem\u003e et al\u003c/em\u003e: A New Technique for Placement of Blocking Screws and its Mechanical Effect on Stability of Tibia Fractures with Distal Fragments after Insertion of Small-Diameter Intramedullary Nails. Orthop Surg 2021, 13(7):2127-2136.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Distal tibial fracture, Intramedullary nails, Kirschner wires, Poller screws, Blocking screws, Fracture fixation","lastPublishedDoi":"10.21203/rs.3.rs-4248223/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4248223/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTo explore the clinical efficacy and safety of Kirschner wires (KWs) as a blocking screw technique for extra-articular fractures of the distal tibia treated with intramedullary nails (IMNs).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFifty-three patients were treated with KW-assisted IMN for extra-articular fractures of the distal tibia via the blocking screw technique or poller screw (PS) technique. The operation time, number of fluoroscopies, number of blocking screws used, blood loss and time to union were compared between the two groups. Additionally, the functional outcomes of the two groups were compared using range of motion (ROM), visual analog scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS), and Lysholm scores.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCompared with those in the PS group, the operation time in the KW group was significantly shorter, and the number of fluoroscopy procedures and amount of blood loss during KW surgery were also significantly lower (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.014, 0.001, and 0.036, respectively). Regarding the functional outcomes, there were no significant differences in the ROM, VAS score, AOFAS score or Lysholm score between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn the treatment of extra-articular fractures of the distal tibia with nails, the use of KW as a blocking screw technique is safe and reliable.\u003c/p\u003e","manuscriptTitle":"Kirschner wires as blocking screws in extra-articular fractures of the distal tibia treated with intramedullary nail","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-19 18:42:29","doi":"10.21203/rs.3.rs-4248223/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a0e06a63-1313-486f-87a6-808e90ce1979","owner":[],"postedDate":"April 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-21T06:26:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-19 18:42:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4248223","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4248223","identity":"rs-4248223","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}