The use of flexible nails in the treatment of paediatric long bone fractures: Experience at a level one paediatric trauma centre, a cohort study.

Introduction: Fractures occur in children at an incidence only surpassed by women >85 years and account for 25 % of paediatric injuries. Over the last three decades, there has been a trend towards operative management of children's fractures including utilisation of flexible nails as popularised by the Nancy group in the 1980s. Between 5 and 11 % of paediatric forearm fractures are now fixed in this manner with complication rates of 12-42 %. This study shares the experience of a paediatric level one major trauma centre using this technique in managing long bone fractures in children. Methods and materials: This retrospective cohort study comprises a sequential series of 109 cases (71 children) of upper and lower limb fractures in children (aged 16 years and below) who underwent fracture fixation using flexible intramedullary nails between 1st April 2015 and 31st March 2019. Radiological and clinical outcomes and complications were assessed. Results: Ninety-three cases (10 in the lower limb, 83 in the upper limb) satisfied the inclusion criteria in 57 children with a mean age of 8.6 years. All cases were successfully reduced intra-operatively and 92 (98.9 %) achieved union. Taking into account all complications in the upper and lower limb, the overall complication rate is 30.1 % (28 cases) with the vast majority (13 cases, 46.4 %) occurring in the upper limb due to prominence of metalwork prompting early removal. Conclusions: This study has shown flexible intramedullary nailing to perform well with good stabilisation of a wide variety of paediatric long bone fractures with restoration of bone alignment, satisfactory outcomes with good union rates and a return to normal function. The technique is also safe and in the upper limb can be performed as day-case surgery by a generalist orthopaedic surgeon. Although the overall complication rate is not insignificant, major complications are rare.

Does medial patellofemoral ligament reconstruction result in femoral tunnel enlargement? A systematic review.

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction is a common surgical procedure for treating patellar instability. The primary aim of this systematic review was to determine whether MPFL reconstruction (MPFLR) leads to femoral tunnel enlargement (FTE). The secondary aims were to explore the clinical effects and risk factors of FTE. Electronic databases (MEDLINE, Global Health, Embase), currently registered studies, conference proceedings and the reference lists of included studies were searched independently by three reviewers. There were no constraints based on language or publication status. Study quality assessment was conducted. 3824 records were screened in the initial search. Seven studies satisfied the inclusion criteria, evaluating 380 knees in 365 patients. Rates of FTE following MPFLR ranged from 38.7 to 77.1%. Five low quality studies reported FTE did not lead to detrimental clinical outcomes as assessed with the Tegner, Kujala, IKDC, and Lysholm scores. There is conflicting evidence regarding change in femoral tunnel width over time. Three studies (of which two had a high risk of bias) reported age, BMI, presence of trochlear dysplasia and tibial tubercle-tibial groove distance did not differ between patients with and without FTE, suggesting these are not risk factors for FTE. CONCLUSION: FTE is a common postoperative event following MPFLR. It does not predispose poor clinical outcomes. Current evidence lacks the ability to identify its risk factors. The reliability of any conclusions drawn is hindered by the low level of evidence of the studies included in this review. Larger prospective studies with long-term follow up are required to reliably ascertain the clinical effects of FTE.

Subjective scar assessment scales in orthopaedic surgery and determinants of patient satisfaction: A systematic review of the literature.

PURPOSE: Scar assessment tools can be utilized during the post-operative period to monitor scar progress. The primary aim of this systematic review was to evaluate current subjective scar assessment scales utilized in orthopaedic surgery. The secondary aim was to identify determinants of patients' satisfaction with their scars and evaluate current measurement scales. METHODS: The preferred reporting items for systematic reviews and meta-analyses checklist was followed. Electronic databases, currently registered studies, conference proceedings and the reference lists of included studies were searched. There were no constraints based on language or publication status. A narrative synthesis provided a description and evaluation of scales utilized in orthopaedic surgery. Determinants of patient satisfaction were identified along with the scales used to measure satisfaction. RESULTS: A total of 6059 records were screened in the initial search. Twenty-six articles satisfied the inclusion criteria, assessing 7130 patients. In the literature, six validated subjective scar scales were identified, including the Vancouver scar scale, patient and observer scar assessment scale, Manchester scar scale, Stony Brook scar evaluation scale, visual analogue scale, and Hollander wound evaluation scale. Studies utilizing these scales to evaluate scars following orthopaedic procedures did so successfully. These were total hip arthroplasty, total knee arthroplasty, and limb reconstruction. The scales demonstrated satisfactory validity. Functional outcomes such as restoration of movement ranked among patients' highest concerns. Scar cosmesis was found to be amongst patients' lowest priorities. CONCLUSIONS: Subjective scar assessment scales identified in the literature were not designed specifically for orthopaedic surgery. However, these were able to appropriately assess scars in the studies identified in this review. Current evidence suggests the effect of scar cosmesis on patient satisfaction with orthopaedic procedures is limited.

Surgical versus non-surgical interventions for treating patellar dislocation.

BACKGROUND: Patellar (knee cap) dislocation occurs when the patella disengages completely from the trochlear (femoral) groove. It affects up to 42/100,000 people, and is most prevalent in those aged 20 to 30 years old. It is uncertain whether surgical or non-surgical treatment is the best approach. This is important as recurrent dislocation occurs in up to 40% of people who experience a first time (primary) dislocation. This can reduce quality of life and as a result people have to modify their lifestyle. This review is needed to determine whether surgical or non-surgical treatment should be offered to people after patellar dislocation. OBJECTIVES: To assess the effects (benefits and harms) of surgical versus non-surgical interventions for treating people with primary or recurrent patellar dislocation. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, AMED, CINAHL, Physiotherapy Evidence Database and trial registries in December 2021. We contacted corresponding authors to identify additional studies. SELECTION CRITERIA: We included randomised and quasi-randomised controlled clinical trials evaluating surgical versus non-surgical interventions for treating primary or recurrent lateral patellar dislocation in adults or children. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were recurrent patellar dislocation, and patient-rated knee and physical function scores. Our secondary outcomes were health-related quality of life, return to former activities, knee pain during activity or at rest, adverse events, patient-reported satisfaction, patient-reported knee instability symptoms and subsequent requirement for knee surgery. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: We included 10 studies (eight randomised controlled trials (RCTs) and two quasi-RCTs) of 519 participants with patellar dislocation. The mean ages in the individual studies ranged from 13.0 to 27.2 years. Four studies included children, mainly adolescents, as well as adults; two only recruited children. Study follow-up ranged from one to 14 years. We are unsure of the evidence for all outcomes in this review because we judged the certainty of the evidence to be very low. We downgraded each outcome by three levels. Reasons included imprecision (when fewer than 100 events were reported or the confidence interval (CI) indicated appreciable benefits as well as harms), risk of bias (when studies were at high risk of performance, detection and attrition bias), and inconsistency (in the event that pooled analysis included high levels of statistical heterogeneity). We are uncertain whether surgery lowers the risk of recurrent dislocation following primary patellar dislocation compared with non-surgical management at two to nine year follow-up. Based on an illustrative risk of recurrent dislocation in 348 people per 1000 in the non-surgical group, we found that 157 fewer people per 1000 (95% CI 209 fewer to 87 fewer) had recurrent dislocation between two and nine years after surgery (8 studies, 438 participants). We are uncertain whether surgery improves patient-rated knee and function scores. Studies measured this outcome using different scales (the Tegner activity scale, Knee Injury and Osteoarthritis Outcome Score, Lysholm, Kujala Patellofemoral Disorders score and Hughston visual analogue scale). The most frequently reported score was the Kujala Patellofemoral Disorders score. This indicated people in the surgical group had a mean score of 5.73 points higher at two to nine year follow-up (95% CI 2.91 lower to 14.37 higher; 7 studies, 401 participants). On this 100-point scale, higher scores indicate better function, and a change score of 10 points is considered to be clinically meaningful; therefore, this CI includes a possible meaningful improvement. We are uncertain whether surgery increases the risk of adverse events. Based on an assumed risk of overall incidence of complications during the first two years in 277 people out of 1000 in the non-surgical group, 335 more people per 1000 (95% CI 75 fewer to 723 more) had an adverse event in the surgery group (2 studies, 144 participants). Three studies (176 participants) assessed participant satisfaction at two to nine year follow-up, reporting little difference between groups. Based on an assumed risk of 763 per 1000 non-surgical participants reporting excellent or good outcomes, seven more participants per 1000 (95% CI 199 fewer to 237 more) reported excellent or good satisfaction. Four studies (256 participants) assessed recurrent patellar subluxation at two to nine year follow-up. Based on an assumed risk of patellar subluxation in 292 out of 1000 in the non-surgical group, 73 fewer people per 1000 (95% CI 146 fewer to 35 more) had patellar subluxation as a result of surgery. Slightly more people had subsequent surgery in the non-surgical group. Pooled two to nine year follow-up data from three trials (195 participants) indicated that, based on an assumed risk of subsequent surgery in 215 people per 1000 in the non-surgical group, 118 fewer people per 1000 (95% CI 200 fewer to 372 more) had subsequent surgery after primary surgery. AUTHORS' CONCLUSIONS: We are uncertain whether surgery improves outcome compared to non-surgical management as the certainty of the evidence was very low. No sufficiently powered trial has examined people with recurrent patellar dislocation. Adequately powered, multicentre, randomised trials are needed. To inform the design and conduct of these trials, expert consensus should be achieved on the minimal description of both surgical and non-surgical interventions, and the pathological variations that may be relevant to both choice of these interventions.

Association between Patellofemoral Anatomy and Chondral Lesions of the Knee in Patellofemoral Instability.

Chondral injury is a serious consequence of patellar dislocation and patellofemoral instability (PFI). There is limited data on the relationship between radiological features such as sulcus angle and patellar height to the presence, location, and severity of chondral lesions. The purpose of this study was to determine the association of anatomical variants in patellofemoral instability with injuries sustained due to patellar dislocation. A cohort of 101 patients who had four or more episodes of dislocation or instability undergoing isolated arthroscopy or arthroscopies at the time of corrective realignment surgery were identified. The prevalence of chondral, ligamentous, and meniscal injuries was determined and correlated to the sulcus angle, tibial tubercle trochlear groove distance, and patellar height on magnetic resonance imaging (MRI) scans. A total of 101 patients was identified. At arthroscopy, the patella demonstrated the highest incidence of chondral injury (68%) followed by the trochlear groove (40%). Lateral meniscal injuries were noted in 6% of patients, medial meniscal injuries in 2%, and anterior cruciate ligament (ACL) injury in 3%. Chondral injuries were graded using the Outerbridge criteria and there was a correlation between more severe chondral injuries and a greater tilt angle (p = 0.05). The occurrence of injury to the lateral meniscus was associated with a higher Insall-Salvati ratio (p = 0.05). More severe chondral injuries are seen in patients with a greater tilt angle.

Regional variation in the provision of major trauma services for the older injured patient.

INTRODUCTION: The establishment of national trauma networks have resulted in significant benefits to injured patients. Older people are the majority of major trauma patients and there is need to study variations in care and performance against clinical metrics for them. We aim to describe this patient group in terms of injury, demographics, episode of care assessment and variation between component regions of the Major Trauma Network of England and Wales. METHOD: The Trauma Audit and Research Network (TARN) database was analysed from April 2017 to March 2019. Patients aged 65 years and above with injury severity score (ISS) greater than eight were selected for analysis. Patients were compared by care pathway in terms of first and second treating hospitals and by demographics, injury mechanism, severity, physiology at arrival to hospital (including Glasgow Coma Score (GCS)) and mortality, where known, at discharge. RESULTS: Fifty-three thousand three hundred and forty-seven older injured patients (median age 82.5 years and 58.2% female), were treated in 165 hospitals within the 17 regional trauma networks over the two-year study period. Aside from GCS and gender, all other patient characteristics were significantly different between networks and specifically, a large variation between the network with the highest proportion of older patients (60.4%) and that with a preponderance of younger patients (40.2%) is seen. 84% of cases were due to a fall <2 m and 36.7% of cases had a brain injury. 73.5% of cases had one or more comorbidities. DISCUSSION: We have increased the understanding of how older patients contribute to and are managed by a national trauma service. We have demonstrated variation in numbers and patient characteristics throughout regional trauma networks. We have detailed the whole patient episode, allowing us to comment on disparities in management such as senior review and access to specialist clinical care settings. Older patients dominate United Kingdom major trauma and considerable variations and shortfalls have been identified. Work is needed to focus on the whole clinical episode for these patients both to improve outcome and patient experience but to also to ensure sustainable clinical care in a resource deplete era.

Increased proportion of alcohol-related trauma in a South London major trauma centre during lockdown: A cohort study.

PURPOSE: Alcohol has been associated with 10%-35% trauma admissions and 40% trauma-related deaths globally. In response to the COVID-19 pandemic, the United Kingdom entered a state of "lockdown" on March 23, 2020. Restrictions were most significantly eased on June 1, 2020, when shops and schools re-opened. The purpose of this study was to quantify the effect of lockdown on alcohol-related trauma admissions. METHODS: All adult patients admitted as "trauma calls" to a London major trauma centre during April 2018 and April 2019 (pre-lockdown, n = 316), and 1st April-31st May 2020 (lockdown, n = 191) had electronic patient records analysed retrospectively. Patients' blood alcohol level and records of intoxication were used to identify alcohol-related trauma. Trauma admissions from pre-lockdown and lockdown cohorts were compared using multiple regression analyses. RESULTS: Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.4%), vs. pre-lockdown 62/316 (19.6%); (odds ratio (OR): 0.83, 95% CI: 0.38-1.28, p < 0.001). Lockdown was also associated with increased weekend admissions of trauma (lockdown 125/191 weekend (65.5%) vs. pre-lockdown 179/316 (56.7%); OR: 0.40, 95% CI: 0.79 to -0.02, p = 0.041). No significant difference existed in the age, gender, or mechanism between pre-lockdown and lockdown cohorts (p > 0.05). CONCLUSIONS: The United Kingdom lockdown was independently associated with an increased proportion of alcohol-related trauma. Trauma admissions were increased during the weekend when staffing levels are reduced. With the possibility of further global "waves" of COVID-19, the long-term repercussions of dangerous alcohol-related behaviour to public health must be addressed.

Reamed intramedullary nailing versus circular frame external fixation for segmental tibial fractures (STIFF-F): a mixed methods feasibility study.

BACKGROUND: Segmental tibial fractures are fractures in two or more areas of the tibial diaphysis resulting in a separate intercalary segment of the bone. Surgical fixation is recommended for patients with segmental tibial fractures as non-operative treatment outcomes are poor. The most common surgical interventions are intramedullary nailing (IMN) and circular frame external fixation (CFEF), but evidence about which is better is of poor quality. An adequately powered randomised controlled trial (RCT) to determine optimum treatment is required. STIFF-F aimed to assess the feasibility of a multicentre RCT comparing IMN with CFEF for segmental tibial fracture. METHODS: STIFF-F was a mixed-methods feasibility study comprising a pilot RCT conducted at six UK Major Trauma Centres, qualitative interviews drawing on Phenomenology and an online survey of rehabilitation. The primary outcome was recruitment rate. Patients, 16 years and over, with a segmental tibial fracture (open or closed) deemed suitable for IMN or CFEF were eligible to participate. Randomisation was stratified by site using random permuted blocks of varying sizes. Participant or assessor blinding was not possible. Interviews were undertaken with patients about their experience of injury, treatment, recovery and participation. Staff were interviewed to identify contextual factors affecting trial processes, their experience of recruitment and the treatment pathway. An online survey was developed to understand the rehabilitation context of the treatments. RESULTS: Eleven patients were screened and three recruited to the pilot RCT. Nineteen staff and four patients participated in interviews, and 11 physiotherapists responded to the survey. This study found the following: (i) segmental tibial fractures were rarer than anticipated, (ii) the complexity of the injury, study setup times and surgeon treatment preferences impeded recruitment, (iii) recovery from a segmental tibial fracture is challenging, and rehabilitation protocols are inconsistent and (iv) despite the difficulty recruiting, staff valued this research question and strived to find a way forward. CONCLUSION: The proposed multicentre RCT comparing IMN with CFEF is not feasible. This study highlighted the difficulty of recruiting patients to an RCT of a complex rare injury over a short time period. TRIAL REGISTRATION: The study was registered with the International Standard Randomised Controlled Trials Number Registry: ISRCTN11229660.

Consensus guidelines for management of patellofemoral instability.

BACKGROUND: The aim of this consensus process was to provide robust national guidelines to assist with decision making with regards to surgical management of patellofemoral instability. METHODS: A national group of surgeons, physiotherapists, basic scientists and a radiologist with expert experience in patellofemoral instability was convened. A formal consensus process was undertaken using validated methodology. They reviewed the existing literature, performed a group consensus meeting to develop recommendations and followed this with a wider consultation meeting with an open invitation for final ratification. The guidelines were reviewed and authorised by the BASK executive committee, followed by the British Orthopaedic Association prior to final publication. RESULTS: The review of the literature confirmed a significant absence of an evidence base to guide clinicians in the surgical management of patellofemoral instability. The consensus process outlined guidance relating to diagnosis and clinical assessment, appropriate imaging modalities, recommendations for surgical options and appropriate post operative physiotherapy. Following wide invitation to contribute to the final document, 102 people responded. Twenty six of those provided additional comments which were blinded, discussed and included or excluded following further discussion amongst the working group. CONCLUSION: Patellofemoral instability is a complex pathology with multiple surgical options available to those who decide surgery is indicated. In the absence of a strong evidence base, these guidelines aim to assist with that decision making process and will pave the way for more robust clinical trials in the future.

Do journals raise their impact factor or SCImago ranking by self-citing in editorials? A bibliometric analysis of trauma and orthopaedic journals.

BACKGROUND: Impact factor (IF) is widely accepted as a measure of a journal's quality but it can be influenced by self-citation. However, the SCImago Journal Rank (SJR) is based on journal prestige, excludes self-citation and considers quality of citations of a journal. This study aimed to investigate journal editors' use of self-citation and whether this correlated with IFs or SJR in trauma and orthopaedic (T&O) journals. METHODS: T&O journals on the SJR database were identified. From each journal, data including country of publication, number of annual issues, IF, SJR indicator and citable articles were extracted. The editorial(s) of each issue in 2018 were reviewed. The total number of times the editors cited their own previous work or their journal (in the preceding 2 years, 2016-2017) were identified. Regression analyses were performed to investigate the association of editorial self-citation with journal IF or SJR indicator. RESULTS: Of the 270 journals identified, 43 T&O journals with 151 editorials were included in the final analysis. A positive correlation between journal self-citation in the editorial and IF (P = 0.02) and SJR indicator (P = 0.02) was found. Citation by editors of their own publications within editorials also positively correlated with IF (P = 0.04) but not for SJR indicator (P = 0.19). There was a positive linear relationship between journal IF and SJR indicators (P < 0.01). CONCLUSION: Editor self-citation influences the IF and SJR indicators in T&O journals. Therefore, these metrics should be considered in conjunction with other factors such as audience, topics included and international presence when evaluating journals.

Antibiotic prophylaxis for urinary catheter manipulation following arthroplasty: a systematic review.

BACKGROUND: Urinary catheter use in the peri- and post-operative phase following arthroplasty may be associated with urinary tract infection (UTI) and deep prosthetic joint infection (PJI). These can be catastrophic complications in joint arthroplasty. We performed a systematic review of the evidence on use of antibiotics for urinary catheter insertion and removal following arthroplasty. METHODS: Electronic databases were searched using the Healthcare Databases Advanced Search interface. Grey literature was searched. From 219 citations, six studies were deemed eligible for review. Due to study heterogeneity, a narrative approach was adopted. Methodological quality of each study was assessed using the Critical Appraisal Skills Programme appraisal tool. RESULTS: A total of 4696 hip and knee arthroplasties were performed on 4578 participants across all studies. Of these, 1475 (31%) were on men and 3189 (68%) on women. The mean age of study participants was 69 years. Three thousand four hundred and eighty-nine cases (74.3%) were related to hip arthroplasty and 629 (13.4%) to knee arthroplasty. Five hundred and seventy-eight (12.3%) were either hip or knee arthroplasty. Forty-five PJIs were reported across all studies (0.96%). Two studies found either no PJI or no statistical difference in the rate of PJI when no antibiotic prophylaxis was used for catheter manipulation. Another study found no statistical difference in PJI rates between patients with or without preoperative bacteriuria. Where studies report potential haematogenous spread from UTIs, this association can only be assumed. Increased duration of urinary catheterization is positively associated with UTI. CONCLUSION: It remains difficult to justify the use of prophylactic antibiotics for catheter manipulation in well patients. Their use is not recommended for this indication.

Four years of experience as a major trauma centre results in no improvement in patient selection for whole-body CT scans following blunt trauma.

INTRODUCTION: Management of major trauma patients with evidence of polytrauma involves the use of immediate whole-body CT (WBCT). Identification of patients appropriate for immediate WBCT remains challenging. Our study aimed to assess for improvement in patient selection for WBCT over time as a major trauma centre (MTC). METHODS: We conducted a retrospective study of patients who presented to our MTC during distinct two-month periods, one in 2013 and the other in 2017. Patients over 18 years of age who presented primarily following blunt trauma and activated a major trauma call were included. All patients underwent either immediate WBCT or standard ATLS workup. Those undergoing WBCT had the results of their scan recorded as positive or negative. RESULTS: A total of 516 patients were included, 232 from 2 months in 2013 and 284 from 2 months in 2017. There was no significant difference in the proportion of patients undergoing WBCT (61.6% vs 59.5%), selective CT (31.9% vs 32.4%) or no CT (6.5% vs 8.1%) between the cohorts. There was no improvement in the rate of negative WBCT observed between 2013 and 2017 (47.6% vs 39.6%, p = 0.17). CONCLUSION: There was no improvement in patient selection for WBCT following trauma at our institution over a three-year period. Optimal patient selection presents an ongoing clinical challenge, with 39-47% of patients undergoing a scan demonstrating no injuries.

Hawthorne effect on surgical studies.

BACKGROUND: The Hawthorne effect or 'observer effect' describes a change in normal behaviour when individuals are aware they are being observed. This may have an impact on effect estimates in clinical trials. The purpose of this study was to determine if the Hawthorne effect had been recorded as a risk of bias in surgical studies. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses compliant literature search was conducted till March 2019. Eligible studies included those reporting or not reporting the Hawthorne effect in surgical studies from the following databases: MEDLINE, Embase, CINAHL, AMED, BNI, HMIC, PsycINFO, Web of Science, Cochrane Library, Google Scholar and OpenGrey. Two reviewers independently reviewed the papers, extracted data and appraised study methods using the Newcastle Ottawa Scale or the Cochrane risk of bias tool. Data were analysed descriptively. RESULTS: A total of 842 papers were identified, of which 16 were eligible. Six (37%) observational studies were identified with the aim of measuring the Hawthorne effect on their outcome with five reporting that the Hawthorne effect was responsible for the improvements in outcomes and one reporting no change in outcome due to the Hawthorne effect. Ten (63%) studies were identified, of which eight used the Hawthorne effect as an explanation to improvements seen in the control group or their secondary outcomes and two to compare their results with other studies. CONCLUSION: There is considerable between-study heterogeneity on how the Hawthorne effect relates to surgical outcomes. Further consideration on reporting and considering the importance of the Hawthorne effect in the design of surgical trials is warranted.

Painful locking screws with tibial nailing, an underestimated complication.

BACKGROUND: Tibial fractures represent approximately 3-4% of reported fractures. Locked, intramedullary nails are commonly used to restore length and alignment and provide rotational stability. Few studies have assessed the complication rate of locking screws. MATERIALS AND METHODS: We conducted a retrospective observational study of all patients who underwent tibial nailing at our institution between the 01/01/15 and 30/06/17. All patients were followed up for at least 1 year post-operatively. For inclusion, patients had to be over 16 years of age and had undergone tibial nail fixation following a traumatic fracture. Post-operative radiographs were used to assess the configuration and features of locking screws. RESULTS: One hundred and twenty-six individuals underwent tibial nailing over the 30-month period, with 95 followed up at least 1 year. Twenty-seven per cent of individuals reported pain attributed to locking screws at follow-up. Upon radiographic assessment, no significant difference was seen between symptomatic and asymptomatic cohorts in terms of proud screw heads proximally (7% vs 5%, p > 0.99) or distally (14% vs 17%, p > 0.99), long screw tips proximally (52% vs 48%, p = 0.81) or distally (51% vs 50%, p > 0.99), or tibiofibular joint penetration proximally (31% vs 23%, p = 0.60). However, there was a higher incidence of distal tibiofibular joint penetration in symptomatic versus asymptomatic individuals (4% vs 25%, p = 0.025). CONCLUSION: Twenty-seven per cent of patients with a tibial nail report painful locking screws. Patients with symptomatic distal locking screws had a higher incidence of radiographic distal tibiofibular joint penetration.