Tibial Malrotation Following Intramedullary Nailing: A Literature Review

The use of intramedullary nail fixation remains the operation of choice for managing unstable and displaced tibia diaphyseal fractures. The literature shows that although commonly performed, there is not a standard approach when performing intramedullary nailing of the tibia; it could be hypothesised that this lack of standardisation may be contributing to the noted complications. This systematic review will look into intramedullary nailing of the tibia in all its parts, from identification of patients through to the surgical procedure techniques and finally the intra- and post-operative complications.  A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Search terms included "tibial intramedullary nail" OR "tibial intramedullary rod" OR "tibial IM nail" OR "tibial interlock" AND "malrotation", and "tibial intramedullary nailing" OR "tibial im nail" OR "tibial interlock" OR "tibial rod" AND "malrotation". Two independent reviewers conducted searches in PubMed, OvidSP for Medline and Embase as well as Cochrane Library using the same search strategy. Searches were conducted on 20 January 2021. Any disagreements were resolved by discussion with a third independent reviewer. This systematic review revealed there are gaps in the literature and in the management process of these patients, and suggested that a systematic approach using 'Get It Right First Time' (GIRFT), intraoperative assessment, validated assessment tools, and imaging postoperatively should be used to improve outcomes. Following the use of this framework, it is hoped that the incidence of malrotation post tibia intramedullary nailing will be reduced, however, it is acknowledged that more high evidence studies need to be carried out and further done to optimise the care of these patients.