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J Orthop Traumatol
J Orthop Traumatol
Journal of Orthopaedics and Traumatology : Official Journal of the Italian Society of Orthopaedics and Traumatology
1590-9921
1590-9999
Springer International Publishing Cham

39249611
780
10.1186/s10195-024-00780-4
Letter to the Editor
Abandoning the use of tension in tibial fracture nailing is associated with lower rate for acute compartment syndrome?
http://orcid.org/0000-0002-5026-4560
Ponkilainen Ville ville.ponkilainen@tuni.fi

Nurmi Heikki
grid.460356.2 0000 0004 0449 0385 Central Finland Central Hospital Nova, Jyväskylä, Finland
9 9 2024
9 9 2024
12 2024
25 4223 2 2024
24 7 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
issue-copyright-statement© Societa Italiana di Ortopedia e Traumatologia (Italian Society of Orthopaedics and Traumatology SIOT) 2024
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pmcDear Editor,

We recently read the article by Honkonen et al. [1] with great interest, as it presented groundbreaking results that could significantly impact the management of tibial shaft fractures, particularly in the context of avoiding unnecessary fasciotomies. However, upon closer examination, we identified a potential confounding bias that warrants recognition.

In their introduction, Honkonen et al. acknowledge previous evidence indicating that calcaneal traction can lead to increased postoperative intracompartmental pressure (ICP) in tibial fractures during intramedullary nailing (IMN) [2]. They also suggest that traction, along with the flexed position of the knee and popliteal support used in the infrapatellar (IP) IMN technique, are considered the main perioperative risk factors for the development of acute compartment syndrome (ACS). However, they fail to discuss the mechanisms by which different approaches (suprapatellar versus infrapatellar) might affect the risk of ACS.

The correlation between traction and increased ICP was previously identified by Shakespeare and Henderson in 1982 [3]. They concluded that for every kilogram of traction applied, the deep posterior pressure rose by 5.7% and the anterior pressure by 1.6%. However, to our knowledge, no studies have explained the bioplausibility behind the correlation between IP IMN and ACS, nor have any studies demonstrated the risk of ACS if both approaches were conducted without traction. This raises the question: is the real reason behind higher ACS rates truly the IP approach, or is it the use of traction?

In the results section, the authors do not describe the most relevant data: the position in which IP IMN was conducted. In the discussion, they mention that all IP IMNs were conducted with traction at that time. Therefore, the results of this study provide more insight into the correlation between the use of traction and ACS than the correlation between SP and IP approaches. As IP IMN can be conducted without traction, the authors should not conclude that the approach is the main issue, but rather the traction itself. Thus, we find it misleading that the title and conclusions focus on the confounder, the approach, rather than traction, despite previous evidence indicating that traction is a risk factor for ACS.

In conclusion, while we appreciate the valuable contribution of Honkonen et al.’s study, we believe that the comprehensive discussion should focus on the role of traction in ACS development rather than the approach. We hope that future studies will address this issue to provide a clearer understanding of the factors contributing to ACS in tibial shaft fractures.

Acknowledgements

None to declare.

Author contributions

V.P. and H.N. are responsible for writing this letter to editor.

Funding

None to declare.

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References

1. Honkonen EE Repo JP Lehtokangas H Luoma E Uimonen M Nurmi S Suprapatellar tibial fracture nailing is associated with lower rate for acute compartment syndrome and the need for fasciotomy compared with the infrapatellar approach J Orthop Traumatol 2024 25 1 5 10.1186/s10195-024-00749-3 38282098
Honkonen EE, Repo JP, Lehtokangas H, Luoma E, Uimonen M, Nurmi S et al (2024) Suprapatellar tibial fracture nailing is associated with lower rate for acute compartment syndrome and the need for fasciotomy compared with the infrapatellar approach. J Orthop Traumatol 25(1):538282098 10.1186/s10195-024-00749-3
2. Kutty S Laing AJ Prasad CVR McCabe JP The effect of traction on compartment pressures during intramedullary nailing of tibial-shaft fractures: a prospective randomised trial Int Orthop 2005 29 3 186 190 10.1007/s00264-005-0651-9 15815904
Kutty S, Laing AJ, Prasad CVR, McCabe JP (2005) The effect of traction on compartment pressures during intramedullary nailing of tibial-shaft fractures: a prospective randomised trial. Int Orthop 29(3):186–19015815904 10.1007/s00264-005-0651-9
3. Shakespeare D Henderson N Compartmental pressure changes during calcaneal traction in tibial fractures J Bone Joint Surg Br Vol 1982 64 4 498 499 10.1302/0301-620X.64B4.7096431
Shakespeare D, Henderson N (1982) Compartmental pressure changes during calcaneal traction in tibial fractures. J Bone Joint Surg Br Vol 64(4):498–49910.1302/0301-620X.64B4.7096431
