Intraoperative fluoroscopic protocol to avoid rotational malalignment after nailing of tibia shaft fractures: introduction of the 'C-Arm Rotational View (CARV)'

Purpose Rotational malalignment (>= 10 degrees) is a frequent pitfall of intramedullary-nailing of tibial shaft fractures. This study aimed to develop an intraoperative fluoroscopy protocol, coined 'C-Arm Rotational View (CARV)', to significantly reduce the risk for rotational malalignment and to test its clinical feasibility. Methods A cadaver and clinical feasibility study was conducted to develop the CARV-technique, that included a standardized intraoperative fluoroscopy sequence of predefined landmarks on the uninjured and injured leg in which the rotation of the C-arm was used to verify for rotational alignment. A mid-shaft tibia fracture was simulated in a cadaver and an unlocked intramedullary-nail was inserted. Random degrees of rotational malalignment were applied using a hand-held goniometer via reference wires at the fracture site. Ten surgeons, blinded for the applied rotation, performed rotational corrections according to (1) current clinical practice after single-leg and dual-leg draping, and (2) according to the CARV-protocol. The primary outcome measure was the accuracy of the corrections relative to neutral tibial alignment. The CARV-protocol was tested in a small clinical cohort. Results In total, 180 rotational corrections were performed by 10 surgeons. Correction according to clinical practice using single-leg and dual-leg draping resulted in a median difference of, respectively, 10.0 degrees (IQR 5.0 degrees) and 10.0 degrees (IQR 5.0 degrees) relative to neutral alignment. Single-leg and dual-leg draping resulted in malalignment (>= 10 degrees) in, respectively, 67% and 58% of the corrections. Standardized correction using the CARV resulted in a median difference of 5.0 degrees (IQR 5.0 degrees) relative to neutral alignment, with only 12% categorized as malalignment (>= 10 degrees). The incidence of rotational malalignment after application of the CARV decreased from 67% and 58% to 12% (p =