There is no difference in prevalence of rotation malalignment following intramedullary nailing of open versus closed tibial shaft fractures

Introduction: Tibial shaft fractures are the most prevalent long-bone fracture and often associated with high energy mechanisms. As a result, 12–15% are seen to been open fractures making up 45% of open fractures. Open fractures are commonly associated with higher complication rates such as infection, and non-union. Intramedullary nails (IMN) are an accepted treatment modality open tibial shaft fractures; however, IMNs are known to be associated with potential rotational malalignment. We hypothesis that an open tibial shaft fracture may in fact be protective against post operative rotational malalignment (RM) given the direct visualisation. Methods: This retrospective study included 268 consecutive patients with a unilateral tibial shaft fracture treated with in IMN between January 2009 and April 2023 within a single level 1 trauma centre. All patients underwent a post-operative bilateral CT for assessment of rotational alignment. Results: RM was observed in 32.8% and 34.4% of patients with closed and open fractures respectively. Indicating no significant difference in the prevalence of RM between fracture groups (p = 0.82). Furthermore, there was no significant difference in the distribution (p = 0.82) and direction of RM (p = 0.11) between the groups. In the closed fracture group left sided fracture led to predominately internal RM whilst nailing of right sided tibial shaft fractures resulted in predominately external RM, this was not re-produced in the open fracture group. Conclusions: The prevalence of RM was not influenced by whether the fracture was open or closed. Hence the choice of surgical approach should rely on factors other than the risk of RM. Level of evidence: Level III.