Nail Plafond Angle: A Novel Technique to Evaluate for Intraoperative Coronal Malalignment in Tibia Fractures

Objective: Orthopedic management of distal tibia fractures presents a difficult challenge with high rates of malignment. Intramedullary nailing demonstrates coronal malalignment rates of 5% to 30%. This malignment has been associated with decreased satisfaction with outcomes. This stresses the importance of obtaining appropriate intraoperative nail alignment. This article helps address the rate of coronal plane malreduction during intramedullary nailing of distal tibial shaft fractures. This novel fluoroscopic technique analyzes the intraoperative angle between the distal end of the tibial nail and the tibial plafond [the nail plafond angle (NPA)]. Materials and Methods: Retrospective review study of 100 subjects with distal tibia fractures at a single level 1 trauma center. Coronal nail alignment was measured on intraoperative fluoroscopic films utilizing the NPA. This measurement was then compared with full-length film alignment postoperatively analyzing for overall malreduction and correlation between the measurements. All measurements were completed by at least 2 orthopedic trained physicians. Results: Coronal alignment was compared, and there was a strong correlation between the measured varus and valgus angulation using the intraoperative technique and the full-length postoperative films (R = 0.74). The overall coronal malalignment while utilizing the NPA technique was 8% (8/100 patients). Discussion: The overall malalignment utilizing the NPA intraoperatively was 8%, which is substantially lower than the generally accepted literature malreduction rate of distal tibia fractures treated with intramedullary fixation. This novel technique could be added to the armamentarium of tools to assist in preventing the malreduction of distal tibia shaft fractures.