Preoperative Evaluation of Intramedullary Tibial Nail Measurements—A Review of the Literature and a New Technique Using Contralateral Radiographs and Digital Planning

INTRODUCTION: An accurate selection of tibial nail and screws measurements is paramount in purpose to achieve proper tibial fracture reduction and fixation, avoid irritation of the soft-tissue envelope, and enable extraction of the nail in the future, if needed. To this date, many methods were suggested to determine the length and diameter of an intramedullary tibial nail, preoperatively and intraoperatively. Each method has its disadvantages, and most are lacking in accuracy. Digital aids are currently available for preoperative planning for many types of surgeries. METHODS: Retrospectively, 27 patients operated for diaphysial tibial fracture intramedullary nailing were selected. The contralateral leg was imaged using AP and lateral radiograph views. Six orthopaedic trauma surgeons used the TraumaCad program (Voyant Health) to plan the appropriate nail and distal locking screws measurements, while blinded from the actual hardware used in the operation. Later, they also conducted quality review regarding the operation carried out and suggested correction in measurements of the hardware. Intra-observer and inter-observer reliability was calculated. RESULTS: The inter-correlation coefficient for the planned nails was 0.97 and 0.84 (P < 0.001) in AP view for length and diameter, respectively, and similarly 0.98 and 0.86 (P < 0.001) in lateral view. The interclass correlation coefficient (ICC) for the locking screws length was 0.7 (P < 0.02) and 0.82 (P < 0.01) for the proximal and distal medio-lateral screws, respectively, and 0.9 (P < 0.001). The ICC between AP and lateral views was 0.98 for length and 0.96 for diameter (P < 0.001). The scores and corrections given by the examiners to the actual selected nail were ICC of 0.98 and 0.96 (P < 0.001) for length and diameter, respectively. The examiners suggested they would correct, post-factum, the length of the nail in average 28% and the diameter in average 30%. The average observer resulted in ICC of 0.94 and 0.91 (P < 0.001) in length and only 0.77 and 0.67 (P < 0.001) in diameter (AP and lateral views, respectively) when comparing the actual nail used and the post-factum plan. CONCLUSION: Preoperative planning of tibial fractures' nailing using imaging of the contralateral leg and a digital graphic planning program is an accurate and reliable method. It may serve to reduce errors, surgical time, and radiation dose in the operating room. This method could also be applied for surgical debriefing.