Intramedullary Nailing as an Effective Alternative to Plating for Far Distal Third Tibial Fractures: Extreme Nailing

Intramedullary Nailing as an Effective Alternative to Plating for Far Distal Third Tibial Fractures: Extreme Nailing | 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 Intramedullary Nailing as an Effective Alternative to Plating for Far Distal Third Tibial Fractures: Extreme Nailing Neel Sharma, Chetan Pradhan, Atul Patil, Chetan Puram, Warid Altaf, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8050483/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 Introduction The management of far 1/3 rd distal tibial metaphyseal fractures presents challenges due to high-energy trauma and extensive soft tissue damage. Traditional treatments like open plating are associated with complications. "Extreme nailing," an alternative approach using intramedullary (IM) nailing at the far ends of the tibia, excluding intra-articular areas offers advantages such as three-directional stability and minimal soft tissue disruption. This study aims to evaluate the efficacy of closed IM nailing in extreme distal tibial fractures for improved outcomes using newer designed nails with advanced features for tibial fixation. Material and methods This study is a 2-year prospective and retrospective cohort study of 30 patients designed to evaluate the functional and radiological outcomes of extreme nailing in the treatment of far distal tibial extra articular fractures. The functional outcome was measured by the AOFAS (American orthopaedic foot and ankle society) scoring system and SF-36 score. The study was done at a tertiary orthopaedic trauma centre with a follow up span of at least 12 months. Results The mean union time was 5 months, and out of 30 patients 5 patients were lost to follow up. As for the remaining 25 patients, 1 patient had non union and 1 had delayed union. 5 patients had implant tip pain within 1 year of surgery. At final follow up all 25 patients could walk full weight bearing without support and without affecting their day-to-day activities. Conclusion This study shows that advanced tibial nails offer stability, reduced tissue damage, and easier insertion, providing rigid internal fixation. This technique allows early mobilization and yields excellent functional and clinical outcomes for extreme tibial fractures with minimal morbidity. Level of evidence: 3 Extreme Nailing Far distal 1/3rd tibial fracture Intra-medullary Nailing Multiplanar interlocking screws Figures Figure 1 Figure 2 Figure 3 Introduction Fractures of the distal metaphysis are often caused by axial and rotational force. Many of them are high-energy injuries and often disrupt the ankle mortise with extensive articular damage. Managing these fractures continues to challenge most orthopaedic surgeons. The particular local anatomic characteristics, high degree of comminution, and soft tissue trauma all contribute to the high rate of complications after open surgical intervention. Since the tibia is a principal load bearing bone in the lower extremity, these fractures can cause extensive morbidity and prolonged disability unless treatment is appropriate. Though many methods have been advocated, the optimal treatment is still under discussion. A variety of treatments have been used before, including plating, intramedullary (IM) nailing, and external fixation. Plate fixation achieves good reduction and rigid fixation and has been widely used in the past, but it requires extensive wound exposure and soft tissue dissection and hence nailing becomes a more suitable option. [ 1 ] Non-articular distal tibial fractures represent approximately 7.2% of all tibial injuries [ 2 ] . The management of these fractures remains challenging and is associated with a higher rate of complications compared to diaphyseal tibial fractures. This is primarily because such injuries often result from severe direct trauma, leading to extensive damage to both the bone and surrounding soft tissues. Consequently, it is preferable to minimize extensive surgical exposure during fixation. Traditional open plating techniques for the distal tibia have been linked to a higher incidence of fixation failure, infection, and wound complications. In contrast, intramedullary nailing, which is well established for diaphyseal tibial fractures, has increasingly been adapted for use in both proximal and distal tibial injuries. This progression has given rise to the concept known as “extreme nailing” [ 3 ] . Extreme nailing in defined as nailing in those fractures which were conventionally plated by fully/minimally open approaches and which are now treated by closed nailing i.e. far proximal and far distal ends of tibial fractures with the exception of intra-articular extension or comminution of extremes ends of tibia. Tibial fractures located at the proximal metaphyseal-epiphyseal area and distal metaphyseal-epiphyseal areas without articular extension are termed as extreme tibial fractures. These fractures pose a technical challenge for surgical management as they are difficult to achieve proper reduction or alignment with the diaphysis and intramedullary nailing (extreme nailing) is a competent method to manage such fractures. [ 4 ] In contrast to conventional plating, intramedullary (IM) nailing of far distal 1/3rd fractures (extreme nailing) provides a less intrusive option for fractures located extremely distally without involvement of the joint [ 6 ] . This method enables improved distribution of loads, minimal tissue damage, and better results in cases of compromised skin conditions. The current study assesses the radiological and functional results of IM nailing in these types of fractures, providing a viable option to plating but with reduced complications and reduced post operative recovery time and is focussed on using intramedullary nailing as a mode of treatment of such fractures with a specific criteria and study parameters Material and Methods This prospective and retrospective cohort study aims to assess the functional and radiological outcomes of "extreme nailing" in the treatment of far distal tibial extra-articular fractures. It was a 2 year cohort study at a level 1 trauma centre which included 30 patients above 18 years of age with closed fractures of the distal third of the tibia who were operated between 2018–2023. Fracture classification was according to the Arbeitsgemeinschaft für Osteo synthesefragen (AO)/Orthopedic Trauma Association (OTA) Classification and included 43-A, 43-B, 43-C not extending into the joint space. Extra-articular fracture was defined as fractures distal to the isthmus of the diaphysis and extending through the flare of the distal tibia 3-4cm away from the joint line [ 5 ] , it was also associated with fibula fracture at a similar level. We also included all open fractures classified as Gustilo-Anderson type 3A, presenting early. Exclusion criteria were fractures with intra-articular extension, comminuted fractures into the joint line, polytrauma, or severe comorbidities such as uncontrolled diabetes or active infection. Patients with open fractures classified as Gustilo-Anderson type 3B or higher were also excluded. Cases involving previous injury to the tibia and/or fibula, segmental tibia fractures, and those with incomplete follow-up, inadequate radiographs, or incomplete data were also excluded (n = 25). The intervention involved using intramedullary nailing (IMN) with advanced tibial nails, featuring multiplanar locking and secure retaining screws, designed for better angular stability in far distal fractures. The surgery was performed at a single orthopaedic trauma centre by 4 experienced surgeons following standardized protocols. Primary outcomes of the study include functional assessment through the American Orthopaedic Foot & Ankle Society (AOFAS) score and radiological evaluation based on bridging callus formation and fracture alignment on postoperative X-rays. Secondary outcomes focus on complication rates, such as non-union, infection, and need for revision surgery, as well as recovery time to full weight-bearing and fracture union. Additionally, quality of life assessments were conducted using the SF-36 score at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Post operatively we intermittently immobilised the limb by giving a long leg knee brace and started knee and ankle range of motion exercises from day 1 of surgery for the patient and mobilized the patient non weight bearing for 6 weeks followed by gradual weight bearing up to 3 months after which the patient was walking full weight bearing without any support. The study spans 24 months, with a follow-up period for each patient of at least one year. Data collection includes baseline assessments, postoperative outcomes and final analysis, leading to the publication of results on extreme nailing in distal tibial fractures. Results In our study, out of 30 patients 5 patients were lost to follow up. The remaining 25 patients from age ranging from 23–70 years (mean age was 44 years) were included. There were 18 males and 7 females in the study. The most common mode of injury was road traffic accident. Out of 25 cases, 2 cases were Gustilo type 1 and the rest were closed injuries. Out of 25 patients, 7 patients had AO type 43 A-1 fracture, 7 had type 43 A-3 and 11 patients had 43 A-2 type of fracture. The average waiting time for the surgery was 12–24 hours and were done by 4 different senior orthopaedic surgeons. Closed intramedullary nailing with advanced tibial nails were done for all patients, in 14 patients additional fibula fixation (TENS nail or fibula plate) was done. Radiologically, out of 25 patients, 9 patients achieved union within 3 months of surgery, 12 patients achieved it in 6 months while 3 patients achieved union by 12 months (Fig. 2). In complications, 1 patient suffered from non-union even after 1 year (smoker) and 1 patient had delayed union by 1 year, 5 patients had distal locking screw tip pain and 3 patients out of them opted for implant removal after fracture osteosynthesis. The AOFAS Score of all the patients that suffered distal tibia fracture and were treated with intramedullary nailing were recorded and it was found that the mean value of the patient immediately post surgery was 27 ± 2, on week 6 it was 50 ± 3.5, week 12 was 67 ± 7, week 24 was 88 ± 11.5 and after a year was 98 ± 3 with a p-value (< 0.001) less than 0.05 at 1 year as per the unpaired t-test (Table 3). Hence there is significant improvement in the AOFAS score in patients after surgery. On SF-36 Scoring, the physical functioning at the end of week 48 for patients that suffered distal tibia fracture was 91.7 ± 8.4 with a physical and emotional role limitation score of 100. The energy at 1 year was 89.3 ± 7 and the emotional well being was 91.6 ± 7.5. The social functioning was 96.7 ± 4.9 and pain was 95.8 ± 5.0 with the general health at 1 year being 71.7 ± 8.8. The data was statistically significant with a p-vale < 0.001. The test used was Trend test. Table 1 Demographic data comparison Parameters Satish Gawali et al [ 9 ] Mugundhan et al [ 15 ] SW Yang et al [ 10 ] Our study Number of patients 60 20 13 25 M:F 40:20 16:4 8:5 18:7 Age 35 35 48.2 ± 19 44 Union time (weeks) 18 11.5 22.6 ± 4.3 20 No. of malunion/nonunion 3 - 3 1 Time of union No. of patients (n = 25) 3 months 9 6 months 12 12 months Non union after 1 year 3 1 Table 2 Radiological results of our study AOFAS(American orthopaedic foot and ankle society score Post op Week 6 Week 12 Week 24 Week 48 p-value (at 1 year) Mean Value 27 ± 2 50 ± 3.5 67 ± 7 88 ± 11.5 98 ± 3 P < 0.001 Table 3. AOFAS Score for distal tibia fracture AOFAS(American orthopaedic foot and ankle society score Post op Week 6 Week 12 Week 24 Week 48 p-value (at 1 year) Mean Value 27 ± 2 50 ± 3.5 67 ± 7 88± 11.5 98 ± 3 P < 0.001 Discussion Treatment of distal tibial meta-diaphyseal fractures can be challenging owing to being related to high energy trauma and often disrupt the ankle mortise extending into the articular surface and cause extensive soft tissue damage, there are various modalities of treating such fracture however the optimal treatment is still under discussion. This study puts light onto a newer concept of intramedullary nailing termed as ‘Extreme Nailing’ a concept first highlighted by Sean E. Nork et al [ 7 ] Extreme nailing addresses fractures traditionally treated with open plating by using closed nailing methods. This approach is suitable for fractures at the far proximal and distal ends of the tibia, except those with intra-articular extensions or severe comminution. Key features include a multi-planar locking pattern, offering five proximal locking options (three within 30mm of the nail top) and four distal locking options (three within 22mm of the nail tip), ensuring superior angular stability compared to conventional intramedullary nails. Enhanced retaining screws provide greater pull-out strength and better torque for reduction, improving bone purchase. The low-profile locking screws feature rounded distal tips to minimize skin prominence. Advanced distal locking options reduce soft tissue damage and enhance distal fragment stability. The nail's improved anatomical bend allows for easier insertion, while innovative locking screws with double lead threads and threads close to the screw head offer better purchase, increased stability, and superior compression for optimal reduction. C.M Robinson et al [ 11 ] in his prospective study on distal metaphyseal fractures of tibia with minimal involvement of ankle reviewed 63 patients with fractures of the distal tibial metaphysis and used the Olured scoring system to assess the functional outcomes. We used the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score which is one of the most commonly used instruments for measuring the outcome of treatment in patients who sustained a complex ankle or hindfoot injury. In our study we used this scoring system to assess the functional outcomes of all patients that suffered distal tibia fractures. In our study and it was found that the mean value of AOFAS Score (Fig. 1 ) immediately post surgery was 27 ± 2, on week 6 it was 50 ± 3.5, week 12 was 67 ± 7, week 24 was 88 ± 11.5 and after a year was 98 ± 3 with a p-value (< 0.001 ) less than 0.05 as per the unpaired t-test. Hence there is significant improvement in the AOFAS score in patients after surgery. While the mean Olured score of ankle symptoms in the mentioned study was 89% . We calculated SF-36 score for all patients separately, none of the 8 components showed any statistically significant data as all had p-values greater than 0.05. This meant that the treatment option led to good return of functions after one year. After doing extensive research we found no other study that used SF-36 as a measurement of functional assessment. We studied the major complications in our group and found that out of 25 where we noted that there was 1 non-union and 1 delayed union, We also tried to study regarding corelation between smoking and non union and found that in our sample only 1 non union patient was a smoker. There were also a few minor complications like implant tip pain and bursitis in 5 out of 25 patients however the pain was not very significant and did not cause any functional limitation to the patient in their daily lives. In our study, we chose not to use Polar screws (blocking screws) to center the guide wire in the larger distal fragment. Mugundhan Moongilpatti Sengodan et al. [ 15 ] recommended the use of blocking screws to guide the nail into the distal fragment and position it centrally. They found that blocking screws are essential for narrowing the metaphyseal canal in distal tibial fractures and directing the nail in the distal fragment, especially when the metaphyseal area lacks stability or when proper reduction is difficult to achieve. The limitations of our study were that we had a very small sample size of 25 patients and did not compare outcomes of nailing to plating for far distal 1/3rd tibial fractures. Thus, the overall results were comparable to other studies and majority of patients had good functional outcome at the end of 1 year. Conclusion Distal metaphyseal and meta-epiphyseal tibial fractures have been traditionally managed with either plating techniques – locking or nonlocking – external fixation devices, limited internal fixation in combination with external fixation, and so on. The indications for locked intramedullary nails have expanded to include these difficult injuries which now include metaphyseal fracture of the far distal 1/3rd and far proximal 1/3rd fractures of the tibia. Indications of tibia nailing can be safely stretched to extremes of either end in conditions like severe swelling, poor skin condition, osteoporosis and can give an equally good result as plating besides preserving the biology adding the advantage of a closed procedure. Extreme nailing in far distal fracture of tibia is a safe, easy to reproduce procedure. However, it is not recommended in intra-articular extension of the fracture. After our study we can state that interlocking nailing is a viable option for treating far distal 1/3rd tibial fracture with minimal soft tissue involvement. Declarations Funding Declaration We hereby declare that there was no funding grants allocated to this research by any funding agencies or organisations and no organisation may gain or lose financially through publication of this manuscript. Authors Contribution All authors made substantial contributions to the conception or design of the work along with the acquisition, analysis and interpretation of data. All authors also drafted the work or revised it critically for important intellectual content. Acknowledgements The author’s wish to thank all researchers whose work was included in this review. No external editorial assistance was used in preparing this manuscript. The author also acknowledges the open-access availability of prior studies that made this study possible. Competing Interests The authors declare that they have no competing interests. There are no financial, professional, or personal conflicts that could have influenced the preparation or publication of this manuscript. Ethics Approval and Consent to Participate The study was submitted and approved by the Institutional Ethics Committee of Sancheti Institute of Orthopaedics and Rehabilitation (Reference No.- IEC-SIOR/AGENDA 055). All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments. Written informed consent to participate in this study was obtained from all individual participants prior to inclusion. Consent for Publication Written informed consent for publication of patient data and accompanying images was obtained from all participants included in the study. Copies of the consent forms are available for review by the Editor of this journal upon request. Availability of Data and Materials The datasets generated and analysed during the current study are not publicly available due to patient confidentiality and institutional policy but are available from the corresponding author on reasonable request, subject to approval by the Institutional Ethics Committee. References Robinson C, McLauchlan G, McLean I, court-Brown C. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing. J Bone Joint Surg Br Vol. 1995;77:781–7. 10.1302/0301-620X.77B5.7559711 . Chiang C-YFC-C, Chuang T-Y, Chiu F-Y, Chen T-H. Interlocking nails for displaced metaphyseal fractures of the distal tibia,Injury,36, Issue 5,2005, Pages 669–74, ISSN 0020–1383. Sean E, Nork P, Tornetta. 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14:58:55","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75917,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8050483/v1/fcbffe9289c0ec08e66e5a11.html"},{"id":99625427,"identity":"fa91fbab-4d91-4d7c-a9d2-619b53fdd5c5","added_by":"auto","created_at":"2026-01-06 14:58:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":13436,"visible":true,"origin":"","legend":"\u003cp\u003eAOFAS Score results\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8050483/v1/7f5017140bf1b800c76dd76c.png"},{"id":99793405,"identity":"3f6a3137-9a50-40a3-a040-a3c2753142a6","added_by":"auto","created_at":"2026-01-08 13:31:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":11612,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier Curve for Time to Union Post Surgery\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8050483/v1/2bd0c896e4144c7fa985795f.png"},{"id":99793768,"identity":"2b6dabae-2f28-4de9-ad94-027dd7f0b591","added_by":"auto","created_at":"2026-01-08 13:32:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":384937,"visible":true,"origin":"","legend":"\u003cp\u003eDistal 1/3\u003csup\u003erd\u003c/sup\u003e tibia nailing with fibula TENS fixation\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8050483/v1/17b2194a3acb4c007c794be8.png"},{"id":101880428,"identity":"cf8e500d-9006-4601-bd6f-b50d0e0a6ff4","added_by":"auto","created_at":"2026-02-04 15:01:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1275536,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8050483/v1/bffe046f-dc94-417e-9c44-aea15a870a2e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Intramedullary Nailing as an Effective Alternative to Plating for Far Distal Third Tibial Fractures: Extreme Nailing","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFractures of the distal metaphysis are often caused by axial and rotational force. Many of them are high-energy injuries and often disrupt the ankle mortise with extensive articular damage. Managing these fractures continues to challenge most orthopaedic surgeons. The particular local anatomic characteristics, high degree of comminution, and soft tissue trauma all contribute to the high rate of complications after open surgical intervention. Since the tibia is a principal load bearing bone in the lower extremity, these fractures can cause extensive morbidity and prolonged disability unless treatment is appropriate. Though many methods have been advocated, the optimal treatment is still under discussion.\u003c/p\u003e \u003cp\u003eA variety of treatments have been used before, including plating, intramedullary (IM) nailing, and external fixation. Plate fixation achieves good reduction and rigid fixation and has been widely used in the past, but it requires extensive wound exposure and soft tissue dissection and hence nailing becomes a more suitable option. \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNon-articular distal tibial fractures represent approximately 7.2% of all tibial injuries \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. The management of these fractures remains challenging and is associated with a higher rate of complications compared to diaphyseal tibial fractures. This is primarily because such injuries often result from severe direct trauma, leading to extensive damage to both the bone and surrounding soft tissues. Consequently, it is preferable to minimize extensive surgical exposure during fixation. Traditional open plating techniques for the distal tibia have been linked to a higher incidence of fixation failure, infection, and wound complications. In contrast, intramedullary nailing, which is well established for diaphyseal tibial fractures, has increasingly been adapted for use in both proximal and distal tibial injuries. This progression has given rise to the concept known as \u0026ldquo;extreme nailing\u0026rdquo;\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eExtreme nailing in defined as nailing in those fractures which were conventionally plated by fully/minimally open approaches and which are now treated by closed nailing i.e. far proximal and far distal ends of tibial fractures with the exception of intra-articular extension or comminution of extremes ends of tibia. Tibial fractures located at the proximal metaphyseal-epiphyseal area and distal metaphyseal-epiphyseal areas without articular extension are termed as extreme tibial fractures. These fractures pose a technical challenge for surgical management as they are difficult to achieve proper reduction or alignment with the diaphysis and intramedullary nailing (extreme nailing) is a competent method to manage such fractures. \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn contrast to conventional plating, intramedullary (IM) nailing of far distal 1/3rd fractures (extreme nailing) provides a less intrusive option for fractures located extremely distally without involvement of the joint \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. This method enables improved distribution of loads, minimal tissue damage, and better results in cases of compromised skin conditions. The current study assesses the radiological and functional results of IM nailing in these types of fractures, providing a viable option to plating but with reduced complications and reduced post operative recovery time and is focussed on using intramedullary nailing as a mode of treatment of such fractures with a specific criteria and study parameters\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eThis prospective and retrospective cohort study aims to assess the functional and radiological outcomes of \"extreme nailing\" in the treatment of far distal tibial extra-articular fractures. It was a 2 year cohort study at a level 1 trauma centre which included 30 patients above 18 years of age with closed fractures of the distal third of the tibia who were operated between 2018\u0026ndash;2023. Fracture classification was according to the Arbeitsgemeinschaft f\u0026uuml;r Osteo synthesefragen (AO)/Orthopedic Trauma Association (OTA) Classification and included 43-A, 43-B, 43-C not extending into the joint space. Extra-articular fracture was defined as fractures distal to the isthmus of the diaphysis and extending through the flare of the distal tibia 3-4cm away from the joint line\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e, it was also associated with fibula fracture at a similar level. We also included all open fractures classified as Gustilo-Anderson type 3A, presenting early. Exclusion criteria were fractures with intra-articular extension, comminuted fractures into the joint line, polytrauma, or severe comorbidities such as uncontrolled diabetes or active infection. Patients with open fractures classified as Gustilo-Anderson type 3B or higher were also excluded. Cases involving previous injury to the tibia and/or fibula, segmental tibia fractures, and those with incomplete follow-up, inadequate radiographs, or incomplete data were also excluded (n\u0026thinsp;=\u0026thinsp;25).\u003c/p\u003e \u003cp\u003eThe intervention involved using intramedullary nailing (IMN) with advanced tibial nails, featuring multiplanar locking and secure retaining screws, designed for better angular stability in far distal fractures. The surgery was performed at a single orthopaedic trauma centre by 4 experienced surgeons following standardized protocols.\u003c/p\u003e \u003cp\u003ePrimary outcomes of the study include functional assessment through the American Orthopaedic Foot \u0026amp; Ankle Society (AOFAS) score and radiological evaluation based on bridging callus formation and fracture alignment on postoperative X-rays. Secondary outcomes focus on complication rates, such as non-union, infection, and need for revision surgery, as well as recovery time to full weight-bearing and fracture union. Additionally, quality of life assessments were conducted using the SF-36 score at 6 weeks, 3 months, 6 months, and 1 year postoperatively.\u003c/p\u003e \u003cp\u003ePost operatively we intermittently immobilised the limb by giving a long leg knee brace and started knee and ankle range of motion exercises from day 1 of surgery for the patient and mobilized the patient non weight bearing for 6 weeks followed by gradual weight bearing up to 3 months after which the patient was walking full weight bearing without any support.\u003c/p\u003e \u003cp\u003eThe study spans 24 months, with a follow-up period for each patient of at least one year. Data collection includes baseline assessments, postoperative outcomes and final analysis, leading to the publication of results on extreme nailing in distal tibial fractures.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn our study, out of 30 patients 5 patients were lost to follow up. The remaining 25 patients from age ranging from 23\u0026ndash;70 years (mean age was 44 years) were included. There were 18 males and 7 females in the study. The most common mode of injury was road traffic accident. Out of 25 cases, 2 cases were Gustilo type 1 and the rest were closed injuries. Out of 25 patients, 7 patients had AO type 43 A-1 fracture, 7 had type 43 A-3 and 11 patients had 43 A-2 type of fracture. The average waiting time for the surgery was 12\u0026ndash;24 hours and were done by 4 different senior orthopaedic surgeons. Closed intramedullary nailing with advanced tibial nails were done for all patients, in 14 patients additional fibula fixation (TENS nail or fibula plate) was done.\u003c/p\u003e \u003cp\u003eRadiologically, out of 25 patients, 9 patients achieved union within 3 months of surgery, 12 patients achieved it in 6 months while 3 patients achieved union by 12 months (Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eIn complications, 1 patient suffered from non-union even after 1 year (smoker) and 1 patient had delayed union by 1 year, 5 patients had distal locking screw tip pain and 3 patients out of them opted for implant removal after fracture osteosynthesis.\u003c/p\u003e \u003cp\u003eThe AOFAS Score of all the patients that suffered distal tibia fracture and were treated with intramedullary nailing were recorded and it was found that the mean value of the patient immediately post surgery was 27\u0026thinsp;\u0026plusmn;\u0026thinsp;2, on week 6 it was 50\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5, week 12 was 67\u0026thinsp;\u0026plusmn;\u0026thinsp;7, week 24 was 88\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 and after a year was 98\u0026thinsp;\u0026plusmn;\u0026thinsp;3 with a p-value (\u0026lt;\u0026thinsp;0.001) less than 0.05 at 1 year as per the unpaired t-test (Table\u0026nbsp;3). Hence there is significant improvement in the AOFAS score in patients after surgery.\u003c/p\u003e \u003cp\u003eOn SF-36 Scoring, the physical functioning at the end of week 48 for patients that suffered distal tibia fracture was 91.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4 with a physical and emotional role limitation score of 100. The energy at 1 year was 89.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7 and the emotional well being was 91.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5. The social functioning was 96.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9 and pain was 95.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0 with the general health at 1 year being 71.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8. The data was statistically significant with a p-vale\u0026thinsp;\u0026lt;\u0026thinsp;0.001. The test used was Trend test.\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\u003eDemographic data comparison\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eSatish Gawali et al\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMugundhan et al\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eSW Yang et al\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e Our study\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e13 25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eM:F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e40:20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16:4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e8:5 18:7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e48.2\u0026thinsp;\u0026plusmn;\u0026thinsp;19 44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eUnion time (weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e22.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3 20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNo. of malunion/nonunion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e3 1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTime of union\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eNo. of patients (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e12 months\u003c/p\u003e \u003cp\u003eNon union after 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\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\u003eRadiological results of our study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAOFAS(American orthopaedic foot and ankle society score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost op\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWeek 6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWeek 12\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWeek 24\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeek 48\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value (at 1 year)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e Mean Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e27\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e50\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e67\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e88\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e98\u0026thinsp;\u0026plusmn;\u0026thinsp;3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e Table 3. AOFAS Score for distal tibia fracture\u003c/p\u003e \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28.6541%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAOFAS(American orthopaedic foot and ankle society score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.301%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost op\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeek 6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeek 12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeek 24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeek 48\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0507%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; p-value (at 1 year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 28.6541%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eMean Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.301%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e27 \u0026plusmn; 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e50 \u0026plusmn; 3.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e67 \u0026plusmn; 7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e88\u0026plusmn; 11.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.9986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e98 \u0026plusmn; 3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0507%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP \u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eTreatment of distal tibial meta-diaphyseal fractures can be challenging owing to being related to high energy trauma and often disrupt the ankle mortise extending into the articular surface and cause extensive soft tissue damage, there are various modalities of treating such fracture however the optimal treatment is still under discussion.\u003c/p\u003e \u003cp\u003eThis study puts light onto a newer concept of intramedullary nailing termed as \u0026lsquo;Extreme Nailing\u0026rsquo; a concept first highlighted by \u003cb\u003eSean E. Nork et al\u003c/b\u003e\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e Extreme nailing addresses fractures traditionally treated with open plating by using closed nailing methods. This approach is suitable for fractures at the far proximal and distal ends of the tibia, except those with intra-articular extensions or severe comminution. Key features include a multi-planar locking pattern, offering five proximal locking options (three within 30mm of the nail top) and four distal locking options (three within 22mm of the nail tip), ensuring superior angular stability compared to conventional intramedullary nails. Enhanced retaining screws provide greater pull-out strength and better torque for reduction, improving bone purchase. The low-profile locking screws feature rounded distal tips to minimize skin prominence. Advanced distal locking options reduce soft tissue damage and enhance distal fragment stability. The nail's improved anatomical bend allows for easier insertion, while innovative locking screws with double lead threads and threads close to the screw head offer better purchase, increased stability, and superior compression for optimal reduction.\u003c/p\u003e \u003cp\u003e \u003cb\u003eC.M Robinson et al\u003c/b\u003e \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e in his prospective study on distal metaphyseal fractures of tibia with minimal involvement of ankle reviewed 63 patients with fractures of the distal tibial metaphysis and used the Olured scoring system to assess the functional outcomes. We used the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score which is one of the most commonly used instruments for measuring the outcome of treatment in patients who sustained a complex ankle or hindfoot injury. In our study we used this scoring system to assess the functional outcomes of all patients that suffered distal tibia fractures. In our study and it was found that the mean value of AOFAS Score (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) immediately post surgery was 27\u0026thinsp;\u0026plusmn;\u0026thinsp;2, on week 6 it was 50\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5, week 12 was 67\u0026thinsp;\u0026plusmn;\u0026thinsp;7, week 24 was 88\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 and after a year was 98\u0026thinsp;\u0026plusmn;\u0026thinsp;3 with a p-value (\u0026lt;\u0026thinsp;0.001 ) less than 0.05 as per the unpaired t-test. Hence there is significant improvement in the AOFAS score in patients after surgery. While the mean Olured score of ankle symptoms in the mentioned study was 89% .\u003c/p\u003e \u003cp\u003eWe calculated SF-36 score for all patients separately, none of the 8 components showed any statistically significant data as all had p-values greater than 0.05. This meant that the treatment option led to good return of functions after one year. After doing extensive research we found no other study that used SF-36 as a measurement of functional assessment.\u003c/p\u003e \u003cp\u003eWe studied the major complications in our group and found that out of 25 where we noted that there was 1 non-union and 1 delayed union, We also tried to study regarding corelation between smoking and non union and found that in our sample only 1 non union patient was a smoker. There were also a few minor complications like implant tip pain and bursitis in 5 out of 25 patients however the pain was not very significant and did not cause any functional limitation to the patient in their daily lives.\u003c/p\u003e \u003cp\u003eIn our study, we chose not to use Polar screws (blocking screws) to center the guide wire in the larger distal fragment. \u003cb\u003eMugundhan Moongilpatti Sengodan et al.\u003c/b\u003e \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e recommended the use of blocking screws to guide the nail into the distal fragment and position it centrally. They found that blocking screws are essential for narrowing the metaphyseal canal in distal tibial fractures and directing the nail in the distal fragment, especially when the metaphyseal area lacks stability or when proper reduction is difficult to achieve.\u003c/p\u003e \u003cp\u003eThe limitations of our study were that we had a very small sample size of 25 patients and did not compare outcomes of nailing to plating for far distal 1/3rd tibial fractures.\u003c/p\u003e \u003cp\u003eThus, the overall results were comparable to other studies and majority of patients had good functional outcome at the end of 1 year.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDistal metaphyseal and meta-epiphyseal tibial fractures have been traditionally managed with either plating techniques \u0026ndash; locking or nonlocking \u0026ndash; external fixation devices, limited internal fixation in combination with external fixation, and so on. The indications for locked intramedullary nails have expanded to include these difficult injuries which now include metaphyseal fracture of the far distal 1/3rd and far proximal 1/3rd fractures of the tibia.\u003c/p\u003e \u003cp\u003eIndications of tibia nailing can be safely stretched to extremes of either end in conditions like severe swelling, poor skin condition, osteoporosis and can give an equally good result as plating besides preserving the biology adding the advantage of a closed procedure. Extreme nailing in far distal fracture of tibia is a safe, easy to reproduce procedure. However, it is not recommended in intra-articular extension of the fracture.\u003c/p\u003e \u003cp\u003eAfter our study we can state that interlocking nailing is a viable option for treating far distal 1/3rd tibial fracture with minimal soft tissue involvement.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe hereby declare that there was no funding grants allocated to this research by any funding agencies or organisations and no organisation may gain or lose financially through publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made substantial contributions to the conception or design of the work along with the acquisition, analysis and interpretation of data. All authors also\u0026nbsp;drafted the work or revised it critically for important intellectual content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author\u0026rsquo;s wish to thank all researchers whose work was included in this review.\u003c/p\u003e\n\u003cp\u003eNo external editorial assistance was used in preparing this manuscript.\u003c/p\u003e\n\u003cp\u003eThe author also acknowledges the open-access availability of prior studies that made this study possible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eThere are no financial, professional, or personal conflicts that could have influenced the preparation or publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was submitted and approved by the Institutional Ethics Committee of Sancheti Institute of Orthopaedics and Rehabilitation (Reference No.- IEC-SIOR/AGENDA 055). All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments. Written informed consent to participate in this study was obtained from all individual participants prior to inclusion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of patient data and accompanying images was obtained from all participants included in the study. Copies of the consent forms are available for review by the Editor of this journal upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to patient confidentiality and institutional policy but are available from the corresponding author on reasonable request, subject to approval by the Institutional Ethics Committee.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRobinson C, McLauchlan G, McLean I, court-Brown C. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing. 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PMID: 9653568.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"Extreme Nailing, Far distal 1/3rd tibial fracture, Intra-medullary Nailing, Multiplanar interlocking screws","lastPublishedDoi":"10.21203/rs.3.rs-8050483/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8050483/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe management of far 1/3\u003csup\u003erd\u003c/sup\u003e distal tibial metaphyseal fractures presents challenges due to high-energy trauma and extensive soft tissue damage. Traditional treatments like open plating are associated with complications. \"Extreme nailing,\" an alternative approach using intramedullary (IM) nailing at the far ends of the tibia, excluding intra-articular areas offers advantages such as three-directional stability and minimal soft tissue disruption. This study aims to evaluate the efficacy of closed IM nailing in extreme distal tibial fractures for improved outcomes using newer designed nails with advanced features for tibial fixation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterial and methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is a 2-year prospective and retrospective cohort study of 30 patients designed to evaluate the functional and radiological outcomes of extreme nailing in the treatment of far distal tibial extra articular fractures. The functional outcome was measured by the AOFAS (American orthopaedic foot and ankle society) scoring system and SF-36 score. The study was done at a tertiary orthopaedic trauma centre with a follow up span of at least 12 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean union time was 5 months, and out of 30 patients 5 patients were lost to follow up. As for the remaining 25 patients, 1 patient had non union and 1 had delayed union. 5 patients had implant tip pain within 1 year of surgery. At final follow up all 25 patients could walk full weight bearing without support and without affecting their day-to-day activities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study shows that advanced tibial nails offer stability, reduced tissue damage, and easier insertion, providing rigid internal fixation. This technique allows early mobilization and yields excellent functional and clinical outcomes for extreme tibial fractures with minimal morbidity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of evidence: \u003c/strong\u003e3\u003c/p\u003e","manuscriptTitle":"Intramedullary Nailing as an Effective Alternative to Plating for Far Distal Third Tibial Fractures: Extreme Nailing","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-06 14:58:50","doi":"10.21203/rs.3.rs-8050483/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":"38bf231f-aa2f-4614-8ca2-77b888f5edce","owner":[],"postedDate":"January 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-31T00:38:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-06 14:58:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8050483","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8050483","identity":"rs-8050483","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}