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How to obtain the desired results from distal tibial nailing based on anatomy, biomechanics, and reduction techniques
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Jungtae Ahn, Se-Lin Jeong, Gu-Hee Jung
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J Musculoskelet Trauma 2025;38(2):74-85. Published online March 31, 2025
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DOI: https://doi.org/10.12671/jmt.2025.00024
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 Abstract
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- Distal tibial metaphyseal fractures are commonly caused by high-energy injuries in young men and osteoporosis in older women. These fractures should be clearly distinguished from high-energy pilon fractures. Although the optimal surgical intervention methods for distal tibial metaphyseal fractures remain uncertain and challenging, surgical treatments for nonarticular distal tibia fractures can be broadly divided into two types: plate fixation and intramedullary nail (IMN) fixation. Once functional reduction is achieved using an appropriate technique, distal tibial nailing might be slightly superior to plate fixation in reducing postoperative complications. Thus, the surgical strategy should focus on functional realignment and proceed in the following sequence: (1) restoring the original tibial length, regardless of whether fibular fixation is to be done; (2) making the optimal entry point through an anteroposterior (AP) projection based on the overlapping point between the fibular tip and lateral plateau margin; (3) placing Kirschner wires (Ø2.4 mm) as blocking pins (in the AP orientation for coronal control and in the mediolateral [ML] orientation for sagittal control) as close to the upper locking hole as possible without causing further comminution on the concave aspect of the short fragment; and (4) making the the distal fixation construct with at least two ML and one AP interlocking screw or two ML interlocking screws and blocking screws. After the IMN is adequately locked, blocking pins (Ø2.4 mm) need to be replaced by a 3.5 mm screw.
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Biomechanical Investigation to Establish Stable Fixation Strategies for Distal Tibial Fractures in Various Situations: Finite Element Analysis Studies
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Sung Hun Yang, Jun Young Lee, Gu-Hee Jung, Hyoung Tae Kim, Ba Woo Ko
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J Korean Fract Soc 2024;37(2):71-81. Published online April 30, 2024
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DOI: https://doi.org/10.12671/jkfs.2024.37.2.71
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Abstract
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- Purpose
This study examined the structural and mechanical stability as well as the clinical significance of various fixation constructs for distal tibial fractures using finite element analysis.
Materials and Methods
Fracture models with 20 mm and 120 mm defects were produced, and implants of an intramedullary nail and anatomical plate model were applied. An axial load of 800 N with 60% distribution in the medial compartment and 40% in the lateral compartment was applied and analyzed using Ansys ® software.
Results
In the intramedullary nail model, the maximum von Mises stress occurred at the primary lag screw hole and adjacent medial cortex, while in the plate model, it occurred at the locking holes around the fracture. The maximum shear stress on the bone and metal implant in the fracture model with a 20 mm defect was highest in the plate assembly model, and in the fracture model with a 120 mm defect, it was highest in the two-lag screw assembly model.
Conclusion
Based on an analysis of the maximum shear stress distribution, securing the fixation strength of the primary lag screw hole is crucial, and the assembly model of the intramedullary nail with two lag screws and a blocking screw applied was the model that best withstood the optimal load. Securing the locking hole directly above the fracture is believed to provide the maximum fixation strength because the maximum pressure in the plate model is concentrated in the proximal locking hole and the surrounding cortex.
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Citations to this article as recorded by  - How to obtain the desired results from distal tibial nailing based on anatomy, biomechanics, and reduction techniques
Jungtae Ahn, Se-Lin Jeong, Gu-Hee Jung
Journal of Musculoskeletal Trauma.2025; 38(2): 74. CrossRef
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Cephalomedullary Nailing with an Additional Cannulated Screw Fixation in Basicervical Femur Fractures
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Keong-Hwan Kim, Woo Dong Nam, Yeon Sik Heo, Gu-Hee Jung
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J Korean Fract Soc 2024;37(1):22-29. Published online January 31, 2024
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DOI: https://doi.org/10.12671/jkfs.2024.37.1.22
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Abstract
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- Purpose
The purpose of this study is to analyze the clinical results of patients with basicervical fracture undergoing cephalomedullary nailing (CMN) with an additional cannulated screw fixation compared to only performing CMN. We hypothesized that a difference may exist in the clinical outcomes if an ad-ditional screw is fixed with CMN compared to only performing CMN in basicervical fracture.
Materials and Methods
A total of 28 consecutive patients who underwent CMN for basicervical fracture were included. In 9 cases, only CMN was conducted, and in 19 cases, an additional cannulated screw fixation was performed with CMN. Bone union, sliding distance, reduction status, and fixation failure were evaluated by postoperative radiography, and ambulatory ability was evaluated by functional results. These findings were compared between a group of CMN and a group of CMN with an additional cannulated screw.
Results
There were 4 males and 24 females with a mean age of 84 years (range, 69–100 years). No significant difference was found in postoperative reduction, tip-apex distance, bone union, and walking function recovery after surgery between the two groups, but in the sliding distance of the lag screw, the CMN group demonstrated more sliding (6.2 mm [range, 2.5–13.4 mm] vs 3.5 mm [range, 0.1– 9.2 mm]; p=0.045). Among the two groups, only one case of fixation failure at the postoperative four months was observed in the CMN group (p=0.321), and hemiarthroplasty with nail construct removal was performed.
Conclusion
CMN with additional cannulated screw fixation is a safe and reliable surgical option in basicervical fracture. It provided favorable clinical outcomes and may be a good alternative for treating basicervical fracture.
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Checkrein Deformity after Fracture
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Jungtae Ahn, Gu-Hee Jung
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J Korean Fract Soc 2024;37(1):60-68. Published online January 31, 2024
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DOI: https://doi.org/10.12671/jkfs.2024.37.1.60
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Abstract
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- Checkrein deformity has dynamic characteristics in which the degree of extension contracture of the metatarsophalangeal joint and flexion contracture of the interphalangeal joint change according to the movement of the ankle joint. Although the primary lesion is the flexor hallucis longus, several clinical features exist because of the accessory connection with the flexor tendon of other toes. After a physical diagnosis, a radiological examination should be performed to determine the cause and location of adhesion. Moreover, it is vital to determine if it is direct adhesion to the tendon tissue or muscle contracture due to ischemic muscle damage. Although there are no clear guidelines for surgical treatment, it can be divided broadly into two methods: soft tissue release and Z-plasty performed through direct access to the lesion site or indirect access through the tarsal tunnel or medial midfoot approach. Direct tendon tissue release surgery should be attempted if the tendon tissue is locally attached to the fracture callus or specific soft tissue. On the other hand, operation on the lesion site should be performed first if the checkrein deformity occurred due to an implant or bone fragments, followed by release surgery. If muscle contracture and movement are limited due to ischemic damage, surgery should be performed to remove adhesions and additional tendon connections around the flexor hallucis longus and digitorum longus by approaching through the tarsal canal and the medial side of the midfoot. The fixed contractures of the metatarsophalangeal and interphalangeal joints should be addressed if the limitations of tendon excursion are identified despite the release techniques.
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Three-Dimensional Analysis of the Morphological Features in the Femur of Atypical Fracture and Practical Implications of Intramedullary Nailing
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Yong Uk Kwon, Kyung-Jae Lee, Joo Young Choi, Gu-Hee Jung
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J Korean Fract Soc 2020;33(2):87-95. Published online April 30, 2020
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DOI: https://doi.org/10.12671/jkfs.2020.33.2.87
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Abstract
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- Purpose
This study analyzed the morphological features of the contralateral femur without an atypical fracture by constructing a three-dimensional model with an actual size medullary canal.
Materials and Methods
Lateral and anterior bowing of the shaft were measured for 21 models, and the shape of the medullary canal was analyzed. To eliminate the projection error, the anteroposterior (AP) femur was rotated internally to the extent that the centerline of the head and neck, which is the ideal position of cephalomedullary nail screw, was neutral, and the lateral femur matched the medial and lateral condyle exactly.
Results
The lateral bowing and anterior bowing was an average of 5.5° (range, 2.8°-10.7°; standard deviation [SD], 2.4°) and 13.1° (range, 6.2°-21.4°; SD, 3.2°), respectively. In the area where lateral bowing increased, the lateral cortex became thicker, and the medullary canal was straightened. On the lateral femur, the anterior angle was increased significantly, and the diameter of curvature averaged 1,370.2 mm (range, 896-1,996 mm; SD, 249.5 mm).
Conclusion
Even if the anterolateral bowing increases in the atypical femur, the medullary canal tends to be straightened in the AP direction. So, it might be considered as a reference to the modification of an intramedullary nail to increase the conformity.
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Computational simulation of coracoclavicular screw insertion through the superior distal clavicular plate for clinical applications in Korean cadavers
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Hyung-Lae Cho, Ji Han Choi, Se-Lin Jeong, Gu-Hee Jung
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Received February 19, 2025 Accepted May 15, 2025 Published online June 26, 2025
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DOI: https://doi.org/10.12671/jmt.2025.00122
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Abstract
- Background
The study was conducted to determine the practical area for inserting the coracoclavicular (CC) screw through the plate by analyzing three-dimensional (3D) shoulder models featuring virtually implanted, actual-size plates and screws.
Methods
Ninety cadaveric shoulders (41 males and 49 females) underwent continuous 1.0-mm slice computed tomography scans. The scan data were imported into image-processing software to generate a 3D shoulder model, including the scapula and clavicle. The overlapping area between the clavicle and the horizontal portion of the coracoid process (horizontal portion_CP) was analyzed in the cranial view. A curved pelvic recon plate was virtually placed on the upper surface of the distal clavicle, and an actual-size (3.5 mm) CC screw was inserted through the plate. Anatomic features were assessed.
Results
The distal clavicle directly overlapped with the horizontal portion_CP in the vertical direction. The overlapping area was sufficient to place the 3.5 mm and 4.5 mm-sized screws. In all shoulder models, the CC screw could be inserted through the plate into the vertical direction, with an average length of 35.5 mm (range, 26.2‒62.5 mm; standard deviation, 1.2 mm). In 87 models, the CC screw was inserted through the third hole from the lateral end of the plate. Two models were inserted through the second hole, and one model through the fourth hole.
Conclusion
The upper surface of the clavicle has sufficient overlapping area to place CC screws through the plate in the vertical direction in the corresponding hole. Supplemental CC screw fixation through the plate can be performed without additional or special equipment.
Level of evidence: IV
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Biomechanical finite element analysis of a Femoral Neck System fixation construct for femur neck fractures and clinical implications
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Hoon-Sang Sohn, Se-Lin Jeong, Gu-Hee Jung
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Received February 18, 2025 Accepted April 17, 2025 Published online June 26, 2025
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DOI: https://doi.org/10.12671/jmt.2025.00108
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Abstract
- Background
This study assessed the structural/mechanical stability of fixation constructs with a Femoral Neck System (FNS) via finite element analysis after simulating femoral neck fractures and explored the clinical implications of the findings.
Methods
We simulated subcapital, transcervical, basicervical, and vertical fracture models using a right femur model (SAWBONES) and imported the implant model of FNS to Ansys (Ansys 19.0, Ansys Inc.) to place the implant in the optimal position. The distal end of the femur model was completely fixed and was abducted 7°. The force vector was set laterally at an angle of 3° and posteriorly at an angle of 15° in the vertical ground. The analysis was conducted using Ansys software with the von Mises stress (VMS) in megapascals (MPa).
Results
The maximum VMS of the fracture site was 67.01 MPa for a subcapital fracture, 68.56 MPa for a transcervical fracture, 344.54 MPa for a basicervical fracture, and 130.59 MPa for a vertical fracture. The maximum VMS of FNS was 840.34 MPa for a subcapital fracture, 637.37 MPa for a transcervical fracture, 464.07 MPa for a basicervical fracture, and 421.01 MPa for a vertical fracture. The maximum VMS of the implant corresponded to the value of the entire fixation construct; thus, FNS mainly functioned as a load-bearing implant. When we compared basicervical and vertical fractures, the stress distribution between the implant and the fracture sites differed significantly, and the basicervical fracture had higher VMS at the bone, implant, and fracture sites.
Conclusions
Considering the stress distribution of the assembly model, FNS fixation should be performed with consideration the osseous anchorage between the proximal bolt and cancellous bone of femoral head, and this technique might be appropriate for vertical fractures. Regarding the VMS at the fracture site, FNS might be applied cautiously only to basicervical fractures with anatomical reduction without a gap or comminution.
Level of evidence: IV.
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