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Year : 2022  |  Volume : 14  |  Issue : 2  |  Page : 134-143

An innovative three stitch technique in tibia interlocking nailing a retrospective analysis

Department of Orthopaedics, Dr. D. Y. Patil Hospital and Research Centre, Navi Mumbai, Maharashtra, India

Date of Submission31-Mar-2021
Date of Acceptance10-Nov-2021
Date of Web Publication30-Dec-2022

Correspondence Address:
Dr. Maitreya Jagdish Patil
Department of Orthopaedics, Dr. D. Y. Patil Hospital and Research Centre, Nerul, Navi Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_21_21

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Introduction: More recent advances are about the incision technique for intramedullary interlocking (IMIL) nailing, a 3 cm stab incision is sufficient for the procedure of IMIL nailing as compared to commonly used suprapatellar incision of 5–7 cm with splitting of patellar tendon which might result in chronic knee pain restricted range of movement, risk of infection, longer duration of postoperative rehabilitation, and poor wound healing. Objective: A retrospective study and analysis of three stitch technique in posttraumatic shaft tibia fractures to assess the range of motion. Background: Tibial shaft fractures have peaked in incidence in the past decade with sky rocketing amount of road traffic accidents. With the mainstay of making any patient of such traumatic incident being early mobilisation, IMIL nailing for tibia remains one of the finest treatment modalities among plating or external fixator applications. With the increased demands in the field of cosmetology and minimally invasive scar techniques, the 3-stitch technique would have a major impact not only on the early healing of surgical scar but also reduced chances of acquired infections along with advancements in weight-bearing exercises. Materials and Methods: A retrospective analysis of midshaft tibia fractures who were treated with IMIL nailing with 3-stitch technique with a sample size of post op 100 patients. A study was held at a tertiary care hospital and research center. Results: Sample size of postoperative 100 patients out of which 76 showed conclusive results and 24 were lost at follow-up. Conclusion: Good to excellent outcome with a small healed scar was observed in patients who underwent 3-stitch technique IMIL nailing for shaft tibia fractures.

Keywords: Intramedullary nailing, minimally invasive, three stitch technique, tibia interlocking nail, tibia shaft fracture

How to cite this article:
Butala RR, Patil MJ, Samant PD, Parelkar KA. An innovative three stitch technique in tibia interlocking nailing a retrospective analysis. J Orthop Traumatol Rehabil 2022;14:134-43

How to cite this URL:
Butala RR, Patil MJ, Samant PD, Parelkar KA. An innovative three stitch technique in tibia interlocking nailing a retrospective analysis. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2023 Apr 1];14:134-43. Available from: https://www.jotr.in/text.asp?2022/14/2/134/365825

  Introduction Top

Most commonly fractured long bone of the body is the tibia and at times fibula as well. Higher incidence of tibia shaft fractures are seen among males that is 21.5/100,000/year and more common between the age groups of 10 and 20, but for females that age group is around 30 and 40 years.[1]

One of the most common causes of shaft tibia fractures in younger age groups is basically high velocity trauma most likely pertaining to road traffic accidents. These lead to either open or compound fractures that may be simple, transverse, oblique, comminuted, or even displaced.

If we consider in the senile age groups, stress or pathological fractures mostly due to fall from height are more common.

Timely mobilization of patients with long bone fractures, such as Tibia, is an important factor so as to avoid further early or delayed complications such as infection or bed sores and even joint stiffness for that matter.[2] Primary motive for the management of tibia fractures pertains to untimely merging of fracture but in an allowable anatomical place along with before time and complete practical return of activity.[3] Nonoperative treatment of closed fractures when managed conservatively like with cast, generally leads to issues such as prolonged immobilization, malunion, shortening, and joint stiffness.[3]

A few highly acceptable treatment modalities for such shaft of tibia fractures which we generally prefer can be intramedullary interlocking nails is well suited for the middiaphysis. Designs of recently developed nails, intramedullary nailing can be done in extra-articular fractures which are adjacent or distant. Nails used in today's times have proximal and distal locking screw holes for better fixation. Apart from nails, minimally invasive percutaneous osteosynthesis (MIPO) plating is used. MIPO aides us to execute a slightest invasive fashion that incorporates closed reduction, extraperiosteal dissection, and relative stability which allows limited controlled motion at the fracture site with secondary bone healing with callus formation.[4] Other methods of fixation generally for compound or even fractures would be external fixator application or even Ilizarov's external fixation that prove essential for limb salvage.

We would be discussing regarding the first and foremost intramedullary interlocking (IMIL) nailing as the commonly used surgical approach for closed shaft of tibia fractures.

  Materials and Methods Top

This retrospective study was conducted from January 2019 to January 2021. The study was conducted at a tertiary care hospital and research center which is attached to a medical college, in the department of orthopedics.

In the study, all 100 patients were involved having acute midshaft tibia or distal end tibia fractures for which treatment modality chosen was IMIL nailing. The following was used as inclusion and exclusion criteria for patients.

Inclusion criteria

  1. Closed fractures – Without any puncture or open wounds
  2. Midshaft tibia fractures – Appropriate for IMIL nailing.
  3. Distal one third tibia fractures – IMIL nailing done for the same
  4. Tibia fractures with or without fibula fractures – Where fibula can be conserved or can be fixed with Titanium Elastic Nailing System (TENS) nail
  5. Patients between age group 20–55 years of age that are skeletally mature (>18).

Exclusion criteria

  1. Proximal one-third tibia fractures
  2. Segmental tibia fractures
  3. Patella fractures
  4. Tibia fractures with femur fractures or ankle fractures
  5. Wounds or abrasions present at incision site
  6. Intra-articular fractures, compound fractures, pathological fractures, any other associated fractures except for ipsilateral fibula
  7. Skeletally immature patients.

Out of the 100 patients, 68 were received in the casualty that is emergency room, whereas 32 reported to the outpatient department. On admission of the patient, a heedful history was extracted from the patient and/or attenders to reveal the mechanism of injury and the severity of the trauma followed by meticulous examination of the patient to assess the fracture.[5]

General condition was evaluated with the vital and systemic examination.

Further examination of other limbs or abrasions present on limbs was done to rule out fractures at other sites. Upon performing local examination of the damaged limb disclosed swelling, deformity as well as function was lost. Whereas on palpation, it was evident about abnormal mobility and crepitus at the fracture site. Distal neurovascular status was assessed by the posterior tibial artery and dorsalis pedis artery pulsations, capillary filling, local temperature, pallor, and paraesthesia.[5]

Once examination was performed, X-rays of the affected extremity were taken most commonly tibia anteroposterior and lateral views. Fractures were classified on the basis of Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification.[6] Once X-rays were done, the extremity was immobilized in plaster of Paris above knee slab given with 10° flexion at the knee and neutral position of the foot. The patient was then admitted to the wards after completing all necessary formalities and preanesthetic checkup was done. Once informed, written and printed consents were taken, the patient was operated under spinal anesthesia.

Preoperatively, one shot of antibiotic, preferably intravenous cefuroxime (1.5 g) was given. The patient was taken in on Operation theatre table in supine radiolucent table. Tourniquet applied on proximal one-third thigh for all surgeries. Once scrubbing, painting and draping was done, tourniquet was inflated to ideal pressure. Knee was flexed to 90°. With the help image intensifier, fractures were reduced. Oblique and spiral fractures were reduced with the help of pointed reduction forceps.

Minimally invasive stab incision was taken which measured not more than 3 cm infrapatellar region and around the ligamentum patellae following which guidewire is inserted. Once it passes the reduced proximal and distal fragment, a reamer was used to ream the tibia. Appropriate sized IMIL nail was attached to the insertion handle and then inserted. Generally, distal locking of the screws was done before proximal. Finally, satisfactory reduction was confirmed under fluoroscopic guidance. Closure was done in layers, starting with patellar tendon and paratendon repair, followed by fascia, subcuticular layer, and skin. The duration of surgery was roughly guessed intraoperatively along with blood loss for all patients.[5]

Postoperatively, anteroposterior and lateral radiographic evaluation was done of tibia. Broad-spectrum antibiotic, such was intravenous cefuroxime (1.5 g), was administered for 5 days in all patients. On postoperative days 2 and 5, inspection of wound was done, and soakage and surgical site were assessed. As far as physiotherapy was concerned, static quadriceps exercises were started on the same postoperative day itself and dynamic quadriceps exercises on postoperative day 0 as well.

Patients began nonweight-bearing walking with walker on day 1 after which, partial weight bearing walking once clinical and radiological signs of bone healing were achieved. Sutures were removed on postoperative day 14. Surgical site was found out to be small as compared to other techniques. Wound healing was faster without any evidence of infection or discharge.

All postoperative patients were followed up at 2 weeks, 3 weeks, 1 month, 3 months, and 6 months. As per follow-up protocols, radiological investigations were done at postoperative 3 weeks, 1 month, and 3 months. Fracture union was defined as healing of at least 3 of 4 cortices on biplanar plain radiograph and possible delayed union was defined as a lack of healing on plain radiograph within 3 months, whereas nonunion was defined as a lack of any healing on plain radiographs within 6 months.[5]

As far as follow-up was concerned, patients were assessed by any complaints such as pain or stiffness in the knee joint or ankle joint, any kind of discharge from surgical sites or any other complaint for that matter. Whether the patient was currently ambulatory that is nonweight bearing, partial weight bearing, or full weight bearing with walker. Radiological image of the tibia in anteroposterior and lateral views was done to assess the fracture site for callous formation, and if the fracture was uniting, united, or there is the presence of malunion, non-union. Any issue in the implants were also noted and checked for, such as broken implants or loosening of screws. Further on, range of motion was thoroughly examined and patients were assessed on basis of pain, any varus, or valgus deformity.

Case 1

A 50-year-old female came to the tertiary care center emergency room with complaints of pain in left lower limb. On further clinical and radiological evaluation, she was a posttraumatic case of left-sided distal one-third tibia shaft and fibula shaft fracture closed with no distal neurovascular deficit DNVD. The patient was an ideal candidate for this study and fit into the inclusive criteria.

Preoperative X-rays

X-rays of tibia anteroposterior and lateral views show distal one-third oblique tibia and fibula shaft fractures.

Intraoperative incision images

Surgical site image

Incision not more than 3 cms taken over infrapatellar region.

Intraoperative fluoroscopy images

Joint space clear and implant fixation achieved with satisfactory reduction.

Postoperative X-rays

Closed reduction internal fixation with IMIL nailing was done for tibia and closed reduction internal fixation with TENS nailing was done for fibula.

Follow-up at 1 month

Minimally invasive healed surgical scar evident.

Range of motion: complete flexion and extension without any pain or deformity.

Case 2

Preoperative X-rays

X-rays of tibia antero-posterior and lateral views show distal 1/3rd comminuted tibia and fibula shaft fractures.

Intra op incision images

Incision not more than 3cms taken over infrapatellar region.

Intra op fluoroscopy images

Joint space clear and implant fixation achieved with satisfactory reduction.

Postoperative X-rays

Precautions to avoid complications

While we reamed we took the following precautions to avoid patellar tendon injury as well as surgical scar complications:

  1. At the incision site, we made sure that we retracted the surgical scar cautiously with 2 curved hemostat forceps along with tissue protector
  2. Curved awl was inserted until medullary canal and flexible reaming was started
  3. Knee was kept in hyperflexion to avoid damage and facilitate easy passage of the flexible reamer
  4. Until the tip of the reamer was completely inserted, we did not start reaming
  5. An adequate number of breaks with an interval of 3 to 5 s were given so that continuous reaming was avoided. (start and stop procedure)
  6. Normal saline wash was being given intermittently During reaming procedure.


HSS scoring system was done for the analysis.

Follow up kept on 1, 3, and 6 months


  • Results 2
  • Gender distribution 2
  • Descriptives for age and surgery details in males and females 2
  • Side affected 3
  • Side operated and gender distribution 3
  • PAIN (HSS-KRS scale) 4
  • FUNCTION (HSS-KRS scale) 5
  • Walking 5
  • Climbing stairs 5
  • Transfer activity 6
  • Outcome in Males 11
  • Outcome in females 11
  • HSS-KRS scale 12
  • Descriptive for HSS-KRS scale in males and females 13
  • Descriptive in different outcomes 15.

  Results Top

Descriptive for age and surgery details in males and females


Climbing stairs

Transfer activity

Outcome in Males

Outcome in females

Descriptives for HSS-KRS scale in males and females

Descriptives in different outcomes

  Results Top

The procedure of three stitch technique was done in closed reduction internal fixation with imil nailing showed good to excellent results over the period of 1 year of follow-up. Out of 100 patients, 76 showed good to excellent results and 24 were lost at follow-up. Over the follow-up mean time for fracture union for most of the patients was found out around 10 to 15 weeks on radiological films. Antero posterior and lateral views were taken at postoperative day 1, day 18, 1 month, 3 months, 6 months, and 1 year.

Patients were operated within 2 days of traumatic injury. Average hospital stay of patients was 1 to 5 postoperative days where check dressing was done on 2nd and 5th day. Physiotherapy exercises began on post op day 1 and were continued even after discharge with partial weight bear walking on 1st day. Minimal stay in the hospital also boosted the morale of the patients.

None of them reported any kinds of implant failures, breakage of implant, backing out of screws, or loosening of screws. Patients showed excellent results in range of motion without any pain in complete flexion and extension at knee joint. Ankle movements were full and free without any restrictions. There was no significant infection noted in any of the patients as they were given intravenous broad-spectrum antibiotics for 5 days followed by oral tablets till suture removal.

The major highlight of the study was found to be minimally invasive surgical scar for entry point of the IMIL nail. Incision taken in most of the surgeries was not more than 3.6 centimetres which was highly favorable for cosmetic purposes. The risk of superficial and deep infections was also reduced significantly. As the scar being trifling, the recovery was even more quicker than expected. In today's era, patients also preferred scarless surgical approach, and ours was almost the same.

IMIL nailing uses the technique of centrally placed guide wire so as to avoid excess of unnecessary or eccentric reaming; this gives the upper hand for better fracture union. Furthermore, early patient mobilisation with physiotherapy exercises at knee and ankle leads to dynamization and advanced bone healing.[5] Clinical thinking has shifted from mechanical concept of absolute stability to the biologic concept of indirect reduction and relative stability using minimally invasive approach.[7]

Good and excellent results found in 3 stitch technique. The excellent results of fracture union were achieved because of closed reduction nailing which does not hamper the fracture hematoma formation. Minimally invasive scar gave the advantage for reduced chances of infection and quicker wound healing.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Larsen P, Elsoe R, Hansen SH, Graven-Nielsen T, Laessoe U, Rasmussen S. Incidence and epidemiology of tibial shaft fractures. Injury 2015;46:746-50.  Back to cited text no. 1
Alho A, Ekeland A, Strømsøe K, Follerås G, Thoresen BO. Locked intramedullary nailing for displaced tibial shaft fractures. J Bone Joint Surg Br 1990;72:805-9.  Back to cited text no. 2
Gupta P, Tiwari A, Thora A, Gandhi JK, Jog VP. Minimally invasive plate osteosynthesis (MIPO) for proximal and distal fractures of the tibia: A biological approach. Malays Orthop J 2016;10:29-37.  Back to cited text no. 3
Gautier E, Sommer C. Guidelines for the clinical application of the LCP. Injury 2003;34 Suppl 2:B63-76.  Back to cited text no. 4
Patil R, Gowaikar A, Shirke A, Lokapur A, Ghelani G, Mehta S. A comparative study of extra-articular distal tibia fractures managed by intramedullary nailing vs locking plate. Int J Orthop Sci 2020;6:224-8. DOI: 10.22271/ortho.2020.v6.i2d.2043.  Back to cited text no. 5
Raja BK, Arun KC, Dheenadayalan J. Classification of distal femur fractures and their clinical relevance. Trauma Int 2016;2:3-6.  Back to cited text no. 6
Baumgaertel F, Buhl M, Rahn BA. Fracture healing in biological plate osteosynthesis. Injury 1998;29 Suppl 3:3-6.  Back to cited text no. 7


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