title: Is device-assisted reduction prior to semi-extended intramedullary nailing of distal tibial fractures necessary?
abstract: BACKGROUND
  Traditional methods of nailing distal tibial fractures have an unacceptable risk of mal-alignment due to difficulty in obtaining and maintaining reduction intra-operatively. Methods to obtain and maintain reduction when nailing these fractures, and therefore reducing the risk of Mal-alignment include modified external fixators, distractors and commercial reduction tools. Semi-extended intramedullary nailing of distal tibial fractures via a supra-patellar approach is now being used more commonly. The aim of this study was to assess whether a commercial reduction device (Staffordshire Orthopaedic Reduction Machine - STORM, Intelligent Orthopaedics, Stafffordshire, UK) is necessary to reduce the risk of mal-alignment in patients undergoing semi-extended nailing for distal tibial fractures.
  
  
  METHODS
  A case-control study was conducted in 20 patients who had STORM-assisted reduction of distal tibial fractures prior to intramedullary nailing and 20 controls without STORM. The control group was matched for age, sex, fracture type (AO/OTA), ASA and gender. All patients had an intramedullary nail (IMN) using the semi-extended system. Primary outcome measures were coronal and sagittal mal-alignment. Secondary outcome measure was unplanned return to theatre for complications and problems with fracture healing.
  
  
  RESULTS
  There was no difference in post-operative mal-alignment in both groups. There was no significant difference in time to union in both groups Both groups had equal number of patients requiring unplanned return to theatre. The STORM group was associated with a significantly increased operative time [p=0.007, 130.3min (SD 49.4) STORM vs 95.6 mins (SD 22.9) Control].
  
  
  CONCLUSIONS
  Intraoperative use of STORM significantly increases operative time with no difference in outcome. The superior orthogonal views and manual control obtained during semi-extended nailing via a supra-patellar approach obviate the need for additional methods: of intraoperative reduction for this fracture group.
authors.affiliation: Core Surgical Trainee (CT2) in Trauma & Orthopaedics Surgery, Royal Liverpool & Broadgreen Teaching Hospital, Prescot Street, Liverpool L7 8XP, United Kingdom. Electronic address: n.j.mehta@doctors.net.uk.
authors.forename: Nisarg
authors.initials: N
authors.lastname: Mehta
authors.affiliation: Core Surgical Trainee (CT2) in Trauma & Orthopaedics Surgery, Royal Liverpool & Broadgreen Teaching Hospital, Prescot Street, Liverpool L7 8XP, United Kingdom.
authors.forename: Veenesh
authors.initials: V
authors.lastname: Selvaratnam
authors.affiliation: Core Surgical Trainee (CT2) in Trauma & Orthopaedics Surgery, Royal Liverpool & Broadgreen Teaching Hospital, Prescot Street, Liverpool L7 8XP, United Kingdom.
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Giotakis
authors.affiliation: Core Surgical Trainee (CT2) in Trauma & Orthopaedics Surgery, Royal Liverpool & Broadgreen Teaching Hospital, Prescot Street, Liverpool L7 8XP, United Kingdom.
authors.forename: Badri
authors.initials: B
authors.lastname: Narayan
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D005260:Female; D005594:Fracture Fixation, Intramedullary / Q000379:methods*; D017102:Fracture Healing; D006801:Humans; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D011859:Radiography; D012189:Retrospective Studies; D013978:Tibial Fractures / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome; D006113:United Kingdom; D019564:Unnecessary Procedures
keywords: Distal tibial fracture; Mal-alignment; STORM; Semi-extended approach; Suprapatellar nailing