By: 13 November 2015
Distal locking of a tibial nail in the presence of a pre-existing distal tibial plate

Distal locking of a tibial nail in the presence of a pre-existing distal tibial plate

Firas Arnaout and Christos Paliobeis share a technical tip to overcome the problem of tibia refracture


Tibia refracture is a common problem among active individuals, with secondary surgery presenting several challenges and difficulties.

Previously implanted metalwork can cause radiographic obstruction to distal locking of intramedullary tibial nails due to radiologic overlap. Full removal of distal tibial plate is associated with significant surgical morbidity and wound complications, as well as increased operative time and X ray exposure.

A simple method to overcome these problems is to only remove some tibial plate screws percutaneously, leaving the plate itself in situ, and using some of the plate holes for distal locking of the tibial nail.


  1. Screws of the tibial plate are removed to allow passage of the nail.
  2. A nail of appropriate length is inserted.
  3. The distal locking hole of the nail is matched with one of the holes of the removed screws under X-ray guidance.
  4. A probing device is used to match the pre-exisiting screw hole with the tibial nail hole.
  5. This is aided by gently moving the nail in the proximodistal direction, as well as gentle rotation.
  6. As the nail reaches its final position, the probing device will go through the appropriate holes within the nail and the bone.
  7. An appropriate locking screw can then be inserted.
  8. It is recommended to use a 4 mm or 5 mm locking screw to provide bony purchase in the pre-existing 3.5 mm screw hole to avoid compromise of fixation.

tibial nail



Removing metal work that has been implanted for many years can be a demanding and risky procedure, with the possibility of failure of removal. Current practice in the surgical treatment of previously fixed tibia refracture is to remove the metalwork prior to refixation [4]. This remains a valid treatment when the above technique has failed.

Another technique used to deal with this problem is to remove the screws and lock the nail distally using newly drilled holes. This runs the risk of creating stress riser from multiple empty drill holes. It would also be technically challenging due to overlapping metalwork making intraoperaitve imaging difficult. In addition, the pre-existing plate will limit possible approaches that increase iatrogenic neurovascular risks.

To try to avoid possible complications, we tried the above technique at our institution and it proved to be a reliable alternative. This straightforward and reproducible method simplifies the surgical treatment of diaphyseal tibial refractures in the presence of previous metalwork, allowing for accurate fracture stabilisation, with minimal soft tissue disruption [1].

Our technique saves time by avoiding removing the tibial plate, and reduces soft tissue dissection by using a single percutaneous incision for removing the pre-existing screw and inserting the replacement locking screw. It also allows the use of a safer technique to reduce neurovascular complications [2].



  1. Bhandari, M; Tornetta, P; Sprague, S, et al. Predictors of reoperation following operative management of fractures of the tibial shaft. Journal of Orthopaedic Trauma: May 2003 – Volume 17 – Issue 5 – pp 353-361
  2. Roberts, CS, King, D, Wang, M, et al. Should distal interlocking of tibial nails be performed from a medial or a lateral direction? Anatomical and Biomechanical Considerations. Journal of Orthopaedic Trauma:: January 1999 – Volume 13 – Issue 1 – pp 27–32.
  3. Anastopoulos G., Ntagiopoulos P.G., Chissas D., et al. Distal locking of tibial nails: a new device to reduce radiation exposure. Clin Orthop Relat Res. 2008 Jan;466(1):216-20. doi: 10.1007/s11999-007-0036-z.
  4. Chrisman, O. Donald M.D., Snook, G.A.. (1968)The problem of refracture of the tibia. Clinical Orthopaedics And Related Research. Volume 60 – Issue – ppg 217-220



Firas Arnaout and Christos Paliobeis, of the department of orthopaedics, Hereford County Hospital, Hereford, UK

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