Low rate of malalignment using the tibial traction triangle for infrapatellar nailing of distal tibia fractures

Objectives: To report on the immediate postoperative alignment of distal tibia fractures (within 10 cm of the tibial plafond) treated with infrapatellar intramedullary nailing (IMN) using the tibial traction triangle (TTT). Methods: We performed a retrospective cohort study at a Level-I academic trauma center, with eighty-one skeletally mature patients with closed distal tibia fractures treated over a 10-year period with closed infrapatellar intramedullary nailing, without fibula fixation, using the TTT. The primary outcome measure is primary malalignment ≥5°. Results: Primary malalignment occurred in 4 (4.9%) patients, all in the coronal plane. Mean coronal plane alignment was 1.72° valgus (range 3° varus to 8° valgus). No sagittal malalignment occurred. The fibula was intact in 5 (6.2%) cases. No patients underwent fibula fixation or blocking screw placement. Intra-articular extension occurred in 28 (34.6%) cases. Mean fracture distance from the plafond was 5.98 cm. Thirty-one patients had a fracture within 5 cm of the plafond, where malalignment was noted in 2 (6.5%) patients. Conclusions: This is the first analysis of a large cohort of patients with distal tibia fractures treated with the TTT. Use of this device leads to a very low rate of primary malalignment with infrapatellar nailing, even in extremely distal fractures. We recommend consideration of this device as one more adjunct to help treat these difficult fractures successfully.