1. < Bones, Joints & Muscles

Tibial Nail Complications- attached image to see hardware

Posted by lucky77 @lucky77, Nov 5, 2022

Hey everyone, I suffered a compound fracture to my tibia and fibula while playing a sport just over a year ago. I had an external fixator put on my leg that day and had tibial nail surgery two days later. I have attached an image from the beginning of my injury to show how the hardware and screws are placed. I have a tibial nail, with two interlocking screws at the top and two at the bottom of my tibia. I went through rehab as prescribed for about 3.5 months and continuously had knee pain on the inside of my knee. I had an MRI done at that point and they believed to not have seen anything wrong. Keep in mind that the MRI would be hard to read because of the metal in my leg. So, I continued through rehab and began to ramp up the weightlifting on my leg, biking, and rowing. While biking I didn’t really ever have pain, while rowing some pain in the shin/knee from the impact at the end of pulls, and weightlifting, I would have medial knee pain in a deep squat, in a lunge, or any movement on my toes, such as a calf raise. I would continue through this for about 3 months, adding in running on an alt G treadmill at the 6 month post op point and whenever I expressed pain, I would be told that everything still needed time to heal and it would eventually get better. So at the 7 month post op point, things weren’t getting better, I had another MRI done and they believed that I had scar tissues near the top of the nail, meniscus damage, and a bone bruise. Again, keep in mind that the MRI is hard to read with the metal in my leg. So, I had a surgery done about 8 months after the original injury to scrape some meniscus and clean out the scar tissue. At this point we thought this was the answer to the problems. I would go on to recover for about a month after this op before beginning to ramp things up again. It was somewhat better, but I still had pain with the same exercises as before, anything in a deep squat, lunge, or on my toes. I would continue through rehab, at the trying to work around these pains, or with them by altering some exercises. At the 9 to 10 month post op point I would begin to start running on turf and an air runner treadmill, this is when I would start to notice a pressure like pain on the inside/front of my shin with the same inner knee pain. We would stop running at this point and I was ordered another MRI on my knee and one on my shin as well. This MRI was done at about the 11 month post op mark. Nothing was found on the lower leg, but for the knee, they believed to see the same bone bruise, the report says mild patchy edema signal posterior lateral tibial plateau and posteromedial femoral condyle. So, we would begin to de-load my leg to let this heal. At the 11.5 month point I would go to to see a specialist and he thought my knee pain was caused by cartilage damage. So, I began to do PRP shots in my knee. Skeptical of this treatment, I received an opinion from another doctor suggesting that it could be the interlocking screw near the top of my tibia causing all of these issues. This leads me to the 12.5 month post op point, to diagnose this, I had a lidocaine shot near the incision of that top screw. I was given exercises to do about an hour after this injection including running, squatting, and a reverse nordic curl. All exercises that caused me trouble in the past. I saw relief in the pressure like pain in my shin, during the run and reverse Nordic curls, but had knee pain through the squats and run. I have an appointment coming up in a couple of days to discuss the possibility of removing the interlocking screws near the top of my tibia. Just curious to hear thoughts from anyone here with previous experience with an injury and surgery similar to mine, I’ve spent a lot of time researching issues with this injury and surgery and wanted to come here as well. Did you get your screws removed? Did screw removal lead to you having pain relief in the knee? Could this be nerve damage from the screw to the saphneous nerve? What are the potential down sides to having the screws removed? Does my experience sound like it would be caused more by the tibial nail itself and not just the screws? Does there appear to be any issues with hardware placement in the attached image? Open to hear any thoughts on this, seeking a life of minimal to no pain again, and continue to be active.

Interested in more discussions like this? Go to the Bones, Joints & Muscles Support Group.

Mentor
Jennifer, Volunteer Mentor | @jenniferhunter | Nov 6, 2022

@lucky77 Welcome to Connect. I appreciate your detailed explanation and questioning of what is wrong and how you are advocating for yourself. Many patients don't understand how to do that, so thank you for your example. We are all patients, and not medical professionals, so we can't diagnose a problem, however we can share similar experience which can give you an insight toward your journey.

It may be that the simple answer could be that hardware causes pain in some people. In my case, I know that is true. I had a compound bimaleolar fracture of the tibia and fibula at the lower ankle end of these bones that was also a dislocation and a serious sprain. I did have some loss of cartilage in the joint, so the joint space is slightly smaller than it should be. It was broken in a movement similar to rolling my ankle and it happened falling off a horse, so it was a high speed impact with the ground. I also had an external fixator cage for a couple weeks before I had surgery at Mayo to place 2 plates on the front and medial side of the tibia, and a screw placed inside the fibula from the lower end upward because it was displaced and had broken through the skin. I had my hardware for about a year and a half before I had it removed. I always felt like someone was kicking me in the shins with every step I took and it throbbed an ached a lot of the time. I also developed extensive chronic hives 6 months after getting titanium plates, and that resolved after hardware was removed.

I have not been able to be as active as previously because every once in a while, my ankle collapses under me with a sharp pain. I think this is when it fatigues, and it just doesn't take much effort until it wears out. That leg is still smaller, and I have weakness in the muscle on the lateral side of the calf and there has been a deficit there with slight muscle atrophy, so my ankle is weak in moving the foot to the lateral side, although it has improved a lot since the cast was removed. With the imbalance between strength of the lateral and medial sides, it allows the strong side to beat up the weak side and stress the tendons and ligaments that were sprained. I am having success with using vet wrap to wrap around my foot to help stabilize it and I have been wearing a lace up ankle brace since the cast came off, and I have custom orthodontics from a podiatrist. I think the joint can shift alignment a bit from laxity in the ligaments, and cause fatigue because it is off just a bit. It also helps to use my hand and rotate the ankle through it's range of motion so it doesn't lock up.

I do well walking on level firm surfaces, but soft uneven ground where my ankle has to stabilize is very difficult and fatigues my ankle quickly. I have learned that it takes time.... lots of time.... and my recovery may be over several years in baby steps. I'm guessing it may be possibly 6 years until I get to maximum recovery, although doctors don't really say that and may not know unless they have had a similar experience. I have talked to my podiatrist about stem cell injections to help heal and clean up the joint, but that needed to wait until at least a year past the last surgery, so I have not done that yet. He said it takes a long time to see results, and it's not a miracle fix, but it can help.

Pain also happens because of scar tissue that can pull on the capsule around a bone where there are lots of nerve endings. You can take your hands and firmly grasp your leg, and pull on the skin and just hold it and wait for the fascia to reorganize itself and release some tension. That is how myofascial release therapy works and I have learned a lot of it working with my therapist. I have also had medial knee pain similar to what you describe, and that was from misalignment of my pelvis. I have worked with a physical therapist on exercises to realign my body and it resolves that, so if that happens it is my clue to check my alignment. Misalignment like that can create wear an tear unevenly leading to a future knee replacement. I pay attention and if I can't solve it, I see my PT.

(Continued in next post)

REPLY
1 reply
Mentor
Jennifer, Volunteer Mentor | @jenniferhunter | Nov 6, 2022
In reply to @jenniferhunter "@lucky77 Welcome to Connect. I appreciate your detailed explanation and questioning of what is wrong and..." + (show)
@jenniferhunter

@lucky77 Welcome to Connect. I appreciate your detailed explanation and questioning of what is wrong and how you are advocating for yourself. Many patients don't understand how to do that, so thank you for your example. We are all patients, and not medical professionals, so we can't diagnose a problem, however we can share similar experience which can give you an insight toward your journey.

It may be that the simple answer could be that hardware causes pain in some people. In my case, I know that is true. I had a compound bimaleolar fracture of the tibia and fibula at the lower ankle end of these bones that was also a dislocation and a serious sprain. I did have some loss of cartilage in the joint, so the joint space is slightly smaller than it should be. It was broken in a movement similar to rolling my ankle and it happened falling off a horse, so it was a high speed impact with the ground. I also had an external fixator cage for a couple weeks before I had surgery at Mayo to place 2 plates on the front and medial side of the tibia, and a screw placed inside the fibula from the lower end upward because it was displaced and had broken through the skin. I had my hardware for about a year and a half before I had it removed. I always felt like someone was kicking me in the shins with every step I took and it throbbed an ached a lot of the time. I also developed extensive chronic hives 6 months after getting titanium plates, and that resolved after hardware was removed.

I have not been able to be as active as previously because every once in a while, my ankle collapses under me with a sharp pain. I think this is when it fatigues, and it just doesn't take much effort until it wears out. That leg is still smaller, and I have weakness in the muscle on the lateral side of the calf and there has been a deficit there with slight muscle atrophy, so my ankle is weak in moving the foot to the lateral side, although it has improved a lot since the cast was removed. With the imbalance between strength of the lateral and medial sides, it allows the strong side to beat up the weak side and stress the tendons and ligaments that were sprained. I am having success with using vet wrap to wrap around my foot to help stabilize it and I have been wearing a lace up ankle brace since the cast came off, and I have custom orthodontics from a podiatrist. I think the joint can shift alignment a bit from laxity in the ligaments, and cause fatigue because it is off just a bit. It also helps to use my hand and rotate the ankle through it's range of motion so it doesn't lock up.

I do well walking on level firm surfaces, but soft uneven ground where my ankle has to stabilize is very difficult and fatigues my ankle quickly. I have learned that it takes time.... lots of time.... and my recovery may be over several years in baby steps. I'm guessing it may be possibly 6 years until I get to maximum recovery, although doctors don't really say that and may not know unless they have had a similar experience. I have talked to my podiatrist about stem cell injections to help heal and clean up the joint, but that needed to wait until at least a year past the last surgery, so I have not done that yet. He said it takes a long time to see results, and it's not a miracle fix, but it can help.

Pain also happens because of scar tissue that can pull on the capsule around a bone where there are lots of nerve endings. You can take your hands and firmly grasp your leg, and pull on the skin and just hold it and wait for the fascia to reorganize itself and release some tension. That is how myofascial release therapy works and I have learned a lot of it working with my therapist. I have also had medial knee pain similar to what you describe, and that was from misalignment of my pelvis. I have worked with a physical therapist on exercises to realign my body and it resolves that, so if that happens it is my clue to check my alignment. Misalignment like that can create wear an tear unevenly leading to a future knee replacement. I pay attention and if I can't solve it, I see my PT.

(Continued in next post)

Jump to this post

@lucky77 (continued from previous post)

It has been a year since my hardware was removed, and the bone pain is gone. My issues are working on the weakness deficit slowly because too much will just cause me pain and to have to get off my foot for a few days to a week to rest it. I do get swelling over the ligaments that were strained in the injury. After hardware removal, you are at risk of fracture because of the holes left by the screws, until the bone heals and fills in the holes. If there was nerve damage during the injury, there could also be weakness or pain that continues. Right after my injury, I could feel a nerve firing, so I straightened my dislocated ankle just enough to stop the nerves from firing with my hands. I didn't want to move it much and cause more damage, but I knew if I just left it like it was, it was pulling hard on a nerve. I loosened my hiking boot, and didn't remove it and I was holding onto it to support my foot. At that time, it hurt a lot to have my fractured ankle dangle. I think that helped prevent some damage, and I always had full sensation and feeling in my foot and ankle. I also could have caused more damage doing that if I had been careless, and it caused a few raised eyebrows at the hospital.

Peripheral nerves do have some ability to regenerate, but that is a question for a doctor and there is likely no definitive answer except wait and see. I also have had problems with metals in my body causing inflammation, so that may have been another source of pain. I had problems with pierced earrings and had to give them up. Dental work caused issues, and I only knew that it was causing inflammation because my asthma got better when I became "metal free." I had some old failing root canals and crowns that were removed when I got ceramic dental implants with ceramic replacement teeth. I was going through that process when I broke my ankle 2 and a half years ago, and my asthma got worse again with titanium metal inside by body. After my surgical hardware removal, I returned again to my metal free status and my lung function improved again.

Removing the fixation hardware was the right choice for me, and I am better off for doing it. There is a recovery again after a surgery, but it isn't as hard as the initial recovery after breaking the bones. I was able to weight bear right away, and was annoyed by stitches again, but this time they got removed a little sooner than the first time. The pain I get now is from ligaments, sometimes aching and sometimes itching (which is the low threshold of pain), but things are improving gradually. The discomfort is minor if I go slow and don't push myself too much. I think I will still improve a lot going forward and I can walk around the block couple times without any pain.

You might want to look at these other discussions where patients discuss hardware removal and our discussion about Myofascial Release.

— Myofascial Release Therapy (MFR) for treating compression and pain:
https://connect.mayoclinic.org/discussion/myofascial-release-therapy-mfr-for-treating-compression-and-pain/

--Hardware removal after tibial plateau fracture (tpf):
https://connect.mayoclinic.org/discussion/hardware-removal-after-tibial-plateau-fracture/

After bone healing is accomplished, perhaps you wouldn't need to keep the hardware if it could be easily removed. Have you discussed removal of all the hardware or just part of it with your surgeon?

REPLY
courtneymeadows | @courtneymeadows | Jul 4, 2023

I had the Tibial nail surgery done over a year ago… I started physical therapy and was back jogging after 6 weeks. Then at week 8 … I had ankle surgery. Since then I have bad pain in the side of my shin and I’ve had a multiple MRI’s, x rays, and everything checked out. I had the screws removed and it didn’t help the pain at all. I am thinking about getting the compartment syndrome surgery because I am on the threshold for having that. I am also thinking about removing the rod but I don’t think that is the problem necessarily since the pain began after the ankle surgery and the pain is on the inside of shin. I am a women college D1 basketball player and had to stop playing because my pain hasn’t been figured out. If anyone has experienced any pain on the inside of their shin and has any suggestions or tips … I would greatly appreciate it!

REPLY
mcleantjg | @mcleantjg | Aug 26, 2023

Interesting. I have been trying to find a group that is having the same issue. I had a severe break of both my tibia and fibula December 28, 2022, from a snow skiing accident. It was a closed fracture. I had surgery immediately and they inserted a 12.5" nail in my tibia.

Fast forward. Started PT at 3 months for 8 weeks. Things have been going well. Many x-rays to confirm things are on track and they appear to be. No MRI has been ordered. Although I am 61, I am in very good physical condition and have always exercised and kept my weight down. Now to my issue. At 8 months, I walk and workout but I still have inflammation at the top of my shin, it feels limpy I assume from the inflammation, and it is itchy from time to time. My ankle/foot also has tingling feeling from time to time. The Orthopedic surgeon said this is normal and may take over a year to completely heal. I am now considering getting a second opinion.

Has anyone else had these types of issues 8 months after surgery?

Thanks -

REPLY
kygirl58 | @kygirl58 | Aug 27, 2023

My husband had a closed compound tib/fib fracture a few years ago. He had a lot of discomfort and tingling just below the knee and at the ankle. His doctor said it was just to be expected. He worked a physical job and was having trouble doing his job. He sought out another orthopedic at about the year mark and he said a lot of people experience this and the nail had done its job so it could come out at that point. He had the nail removed and all the discomfort stopped. He was very glad he made the decision to do so! It wasn’t s bad surgery to have it removed.
I’d check with another orthopedic and get another opinion.
Best of luck!

REPLY
mcleantjg | @mcleantjg | Sep 1, 2023

Thank you! I am scheduled for a second opinion. Did he have inflammation on the front of his tibia?

REPLY
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