Tibial nail starting point

Establishing an accurate starting point continues to play a all-important role in any intramedullary breeze through procedure. Research studies have provided important information on the anatomic location of the ideal starting sharpen for intramedullary pinpoint of tibia fractures [ 9 – 11 ]. These investigations demonstrated that the ideal starting detail lies at the anterior border of the tibial tableland and merely medial to the lateral tibial spur. furthermore, Tornetta et alabama. [ 11 ] reported on a dependable zone with a width of 22.9 mm ± 8.9 millimeter which allows for a safe breeze through interpolation without the gamble of damage to the adjacent articular structures. traditionally, the start period for intramedullary pinpoint of tibial rotating shaft fractures has been established through an infrapatellar approach either by splitting the patellar tendon ( transtendinous overture ) or alternatively by dissecting just adjacent to the patellar tendon ( paratendinous approach path ). Using this traditional proficiency, the knee is resting over the radiolucent triangle in a flex or hyperflexed position. The radiolucent triangle serves as a device to placement the stage in a flex position while the starting sharpen is established. The radiolucent triangle may besides assist in applying traction during the decrease tactic and nail insertion. Nailing in the semiextended position has recently gained significant attention in the orthopedic literature [ 12 – 15 ]. Nailing in the semiextended put using a medial parapatellar approach has been suggested by Tornetta and Collins as a method acting to avoid apex anterior deformities [ 16 ]. late reports have adopted this concept suggesting tibial breeze through in the semiextended military position using a suprapatellar portal and collar insertion through the patellofemoral joint [ 14, 15 ]. Over the last years, surgical orchestration has been developed for this technique in order to allow the routine to be performed in a dependable fashion and with minimal price to the adjacent intraarticular structures. The procedure is performed with the knee flexed approximately 15–20 degrees. An approximately 3 curium longitudinal incision is made about one to two fingerbreadths above the patella. The quadricepts tendon is split in a longitudinal fashion and the patellofemoral joint is entered through far blunt dissection. A cannula system with a blunt trochar is then inserted through the patellofemoral joint in order to establish the startle decimal point at the junction of the anterior cortex of the proximal tibia and the articular surface ( Fig. 4a – b ). The starting decimal point is established under fluoroscopic guidance using a 3.2-mm guide pin rigorously adhering to the fluoroscopic landmarks described above. A multiholed scout peg sleeve is available and may allow for fine adjustments of the begin distributor point. The remaining surgical procedure including ream of the canal and tibial nail interpolation is performed through the cannula system which allows for condom auspices of the surrounding soft tissues and articular structures .Fig. 4figure 4 ab Intraoperative mental picture ( a ) demonstrating the suprapatellar begin period through a longitudinal disconnected of the quadriceps tendon and cannula insertion through the patellofemoral joint. Corresponding intraoperative fluoroscopic pictures with lateral watch of the starting indicate ( b ) Full size picture

Suprapatellar pinpoint in the semiextended position offeres several potential advantages. The semiextended leg military position potentially facilitates the fault reduction in particular in proximal third base tibial fractures with the typical vertex anterior disfigurement. In these injury patterns, hyperflexion of the knee over the radiolucent triangle may exaggerate the existing vertex anterior disfigurement. In contrast, the semiextended side may eliminate the extension force of the quadriceps and may greatly facilitate the decrease of the apex front tooth angulation. furthermore, the leg resting on the manoeuver room table may facilitate the maneuver of the leg during the surgical operation and may facilitate the entree of the fluoroscopic double intensifier. Suprapatellar pinpoint in the semiextended position may besides represent a feasible option to the traditional infrapatellar approach when voiced weave injuries around the infrapatellar area make the placement of surgical incisions undesireable ( Fig. 5 ) .Fig. 5figure 5 Intraoperative video demonstrating the cushy weave injury to the infrapatellar area as an indication for suprapatellar breeze through in the semiextended place Full size trope recently published studies have suggested suprapatellar tibial collar technique in the semiextended position as a safe and effective surgical technique. however, there surely remains the concern of iatrogenic damage to structures of the patellofemoral roast. Using a cadaver mannequin, Gelbke et aluminum. [ 13 ] measured the reach pressures in the patellofemoral joint during suprapatellar pinpoint in the semiextended situation versus infrapatellar smash. These authors reported higher point pressures with the suprapatellar collar technique. however, the authors besides reported that the watch peak pressures were well below the doorway that has been reported to be damaging to articular cartilage and they concluded that suprapatellar smash in the semiextended position represents a safe surgical proficiency [ 13 ]. In a prospective clinical study including 56 patients undergo suprapatellar tibial collar in the semiextended placement, Sanders et alabama. [ 15 ] did not identify any meaning sequela affecting the patellofemoral cartilage as per Magnetic Resonance Imaging and arthroscopic follow-up evaluations. Interestingly, no affected role in this series complained of front tooth knee pain at the 12 months follow-up. In a retrospective cohort report, Jones et aluminum. [ 14 ] recorded the outcomes of 38 patients undergo suprapatellar breeze through in the semiextended position versus 36 patients undergo infrapatellar nail down. These authors reported no differences in front tooth knee trouble and no functional differences between the two affected role groups at a minimum of 12 months follow-up. furthermore, these investigators reported significantly better fracture reductions and more precise starting points in the suprapatellar pinpoint group. These promising data suggest that suprapatellar tibial nail in the semiextended position represents a safe surgical proficiency and appropriate clinical and radiographic outcomes can be achieved using this approach. however, future clinical trials are required to further study the advantages and disadvantages of suprapatellar collar and to evaluate the long-run outcomes associated with this technique .

Reduction techniques

placement of the tibial smash alone does not result in adequate fracture decrease and allow fault alliance must be maintained throughout the ream action and collar placement. While application of longitudinal grip typically results in better fracture alignment through ligamentotaxis, the simpleton application of manual grip by itself may not constantly achieve an anatomic fracture conjunction. Various closed, minimal encroaching, and open reduction maneuvers have been described and should be in the surgeons armamentarium .

Technical trick

Closed reduction maneuvers can be facilitated by widely available reduction tools, such as the F-tool. The F-tool is a an F-shaped radiolucent reduction device that will allow for correction of varus/valgus angulation as well as correction of medial/lateral translation (Fig. 6 ad ). However, due to significant pressure on the tissues prolonged application of this reduction device should be avoided. Certain fractures are also amenable to placement of percutaneously placed reduction clamps. In particular, spiral and oblique fractures lean themselves towards placement of percutaneous clamps. These clamps can be applied in a soft tissue friendly manner through small stab incisions (Fig. 7 ac ). The type of the clamp and the location of the surgical incisions should be strategically chosen in order to minimize any prolonged soft tissue compromise from clamp placement (Fig. 8 ab ).Fig. 6figure 6 ad The F-tool ( a ) allowing for reduction of a medially translated tibia fracture ( bd ) Full size personaFig. 7figure 7 ac A percutaneously placed periarticular clamp ( a ) allowing for reduction of a distal third coil tibia fracture ( bc ) Full size pictureFig. 8figure 8 ab In like affected role, a percutaneously placed pointed reduction clamp ( a ) resulted in significant soft tissue compromise ( b ) which required changing to a different clamp Full size effigy

The universal distractor can be used as an extra reduction instrument [ 17 ]. The universal distractor may assist in maintaining length and alliance. careful attention must be paid to the placement of the Schanz pins. These are placed from the medial side into the proximal and distal shard away from the planned position of the tibial nail. furthermore, the proximal Schanz personal identification number can be placed in a place that mimics the stead of a proximal forget screw [ 17 ]. This may become peculiarly utilitarian when seeking fracture reduction in proximal tibia fractures with the distinctive vertex anterior deformity. similar to the universal distractor, two-pin external arrested development can be used to obtain and maintain length and conjunction during intramedullary breeze through of tibial beam fractures [ 18 ]. When using this proficiency, the pin placement should follow the same principles as with the manipulation of the universal distractor. In some instances closed and minimal invasivive reduction techniques remain insufficient in obtaining an anatomic fracture alignment. In these cases, candid decrease techniques with respectful handling of the surrounding delicate tissues should be considered [ 19, 20 ]. open reduction techniques allow for surgical reduction under aim visual image. likely disadvantages of open decrease techniques include the extra surgical dissection which in may potentially increase the risk of surgical site infection. furthermore, the extra strip of the blood supply to the fracture site may potentially increase the risk of subsequent fracture nonunion. however, retrospective age group studies have not shown any increased gamble of surgical site infection or fracture nonunion with the use of open reduction techniques [ 19, 20 ] .

Technical trick

Open reduction maneuvers do not only allow for placement of appropriate surgical reduction clamps, but also provide the opportunity to apply a small- or mini-fragment plate at the fracture site in order to achieve and maintain fracture reduction during the intramedullary nailing procedure [ 17, 21 ] . The plates are secured to the proximal and distal fracture fragments using unicortical screws. The plate is then maintained throughout the reaming procedure and placement of the intramedullary tibial nail. Following nail placement the plate can be removed or alternatively be left in situ in order to enhance the stability of the fixation construct (Fig. 9 a e ). If the surgeon chooses to leave the plate in situ, the unicortical screws should be exchanged against bicortical screws. Unicortical plating or “reduction plating” has been suggested as a safe and effective technique and should be considered for select cases of tibial shaft that require an open approach to achieve an acceptable fracture reduction [ 17, 21 ] .Fig. 9figure 9 ae Open tibia fracture with significant comminution and bone loss ( a ). A unicortical plate was applied through the traumatic wind to achieve fracture reduction ( b ). The plate was maintained throughout the ream process and complete placement ( c ). Following successful collar stabilization, the plate was removed ( de ) Full size picture

Blocking screws ( or “ poller ” screw ) have been popularized by Krettek et alabama. [ 22 ]. The purpose of blocking screws is to narrow the canal in the metaphyseal sphere and to substitute a insufficient cerebral cortex. consequently, blocking screws are utilitarian tools in fractures with metaphyseal participation. The blocking screws are placed prior to the ream process and collar placement. Blocking screws are typically placed in the short, articular fragment and on the concave slope of the disfigurement. For case, the typical deformity of a proximal third base tibia fracture is characterized by a valgus- and vertex anterior deformity. In order to overcome the valgus deformity, a blocking cheat can be placed in an anterior to posterior direction into the lateral assign of the proximal fracture fragment ( i.e. on the concave side of the disfigurement ). This blocking fuck is used to guide the nail medially and therefore prevents a valgus angulation. similarly, the vertex front tooth disfigurement can be overcome by a block screw that is placed in a median to lateral focus in the back tooth fortune of the proximal fragment ( i.e. on the concave side of the deformity ) ( Fig. 10a – barn ). Krettek et aluminum. [ 22 ] reported on 21 tibial fractures treated with intramedullary tibial nail plus blocking screws. These authors reported favorable clinical and radiological outcomes and no complications related to the placement of blocking screws. Ricci et alabama. [ 23 ] reported on 12 patients underoing tibial collar in junction with blocking screws. All but one affected role went on to fracture union. The authors reported only one patient with an angular disfigurement of more than 5 degrees. This patient was found to have a postoperative valgus angulation of 10 degrees. however, this affected role had not undergo blocking sleep together placement to control for valgus angulation .Fig. 10figure 10 ab Blocking screw placed anterior to posterior on the lateral side to prevent valgus disfigurement ( a ). Blocking prison guard placed posteriorly from median to lateral preventing apex anterior disfigurement ( b ) Full size effigy

Reaming of the intramedullary canal

Upon successful completion of the fracture decrease, the intramedullary cavity is prepared for the placement of the tibial complete. A ball-tipped template wire is typically inserted into the tibial duct and across the fracture site. The reamers vitamin a well as the tibial nail are passed over the ball-tipped steer cable. consequently, it is very important to confirm on fluoroscopic images that the ball-tipped guide cable is positioned appropriately. In particular, it is crucial to confirm that on the charge of the ankle joint, the ball-tipped guide wire is well-centered both on the anteroposterior angstrom well as the lateral pass view ( Fig. 11a – boron ). Following allow placement of the ball-tipped guidebook wire, the ream process is initiated to prepare the intramedullary cavity for the nail placement .Fig. 11figure 11 ab Anteroposterior ( a ) and lateral pass ( b ) fluoroscopic pictures demonstrating center/center position of the ball-tipped guidewire Full size image It appears that at many academic injury centers reamed tibial collar is preferred over unreamed tibial smash [ 1 ]. however, the write out of ream versus unreamed tibial nail has been discussed controversially. It has been suggested that reamed complete allows for placement of larger size nails allowing for increase biomechanical stability and potentially improved fracture healing [ 24 ]. In contrast, it has been reported that intramedullary reaming results in significant compromise of the endosteal rake provide which may potentially limit the biological healing reception at the fracture site [ 25 ]. furthermore, the business remains that the reaming procedure may increase the hazard of fat embolization and pneumonic failure [ 26, 27 ]. respective prospective randomized clinical trials have compared reamed versus unreamed tibial breeze through [ 1, 24, 28 – 33 ]. In 2008, the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures ( SPRINT ) was published [ 1 ]. With a sum of 1319 enroll subjects, this discipline represents one of the largest prospective randomized clinical trials in the orthopedic literature overall. These authors reported that among all fractures the risk of a primary event ( re-operation and/or autodynamization ) was not significantly different between reamed and unreamed tibial complete. A subgroup analysis showed no differences between the two treatment groups in open tibial fractures. In close tibial fractures, the risk of a elementary event was significantly higher for unreamed tibial collar. however, this deviation was largely driven by the least important outcomes, dynamization and autodynamization. furthermore, the authors reported that the treat surgeons had relatively more know with ream tibial breeze through. With regards to adverse events, the authors recorded a significantly higher death rate in reamed tibial complete. The investigators noted that blinded adjudicators classified all deaths as unrelated to the intramedullary collar procedure [ 1 ]. subsequent meta-analyses vitamin a well as a Cochrane review were published with the captive to obtain pool results from the above mentioned randomize clinical trials [ 34 – 37 ]. The results of these meta-analyses were largely dominated by the results from the SPRINT study [ 2 ] due to its big sample distribution size. therefore, the results of the above mentioned meta-analyses [ 34 – 37 ] were overall in line with the results from the SPRINT cogitation [ 1 ] and by and large confirmed its findings. We suggest that most surgeons in North America prefer reamed intramedullary tibial smash over unreamed breeze through. however, both reamed and unreamed intramedullary breeze through can be suggested as satisfactory standard techniques and good outcomes can be achieved with both of these methods .

Placement of interlocking screws

The function of interlocking screws in tibial shaft fractures is to prevent shorten and malrotation. The presentation of interlocking screw has expanded the indication for intramedullary tibial collar to more proximal and distal third base tibial diaphysis fractures with metaphyseal participation. In fractures involving the metaphyseal sphere, interlocking screws become more important in maintaining axial alliance due to the absence of a potent nail/cortex interface. As of today, there are no established clinical guidelines that are providing strong recommendations how many proximal and distal mesh screws are required for the different fracture types. Most literature in this field is limited to biomechanical investigations and published clinical result data is limited. In a human cadaver model simulating proximal tibia fractures treated with intramedullary nail, Laflamme et aluminum. [ 38 ] reported that the construct constancy of two cross proximal interlocking screws can be importantly increased by the addition of two devious proximal interlocking screws. In a different human cadaver model simulating intramedullary breeze through of extraarticular proximal tibia fractures, Hansen et aluminum. [ 39 ] compared the biomechanical stability of two versus three proximal interlocking screws. These authors reported significantly greater constancy with three proximal interlocking screws. Using a distal tibia fracture model, Chan et aluminum. [ 40 ] compared two versus three distal interlocking screws. These investigators suggested that both fixation constructs provided sufficient stability to allow for postoperative weight-bearing. however, the three-screw fixation construct provided significantly greater stability than the two-screw fixation construct [ 40 ]. furthermore, recent studies suggested that slant stable interlocking screws may provide greater constancy than conventional interlock screws, which may allow for potentially achieving the lapp construct stability with a lower phone number of interlocking screws [ 41, 42 ]. Clinical data providing higher level of tell with regards to the want number and cofiguration of interlocking screws in tibial pinpoint remains limit. In a retrospective clinical sketch evaluating the outcomes in distal tibia fractures undergoing intramedullary nail down, Egol et alabama. [ 43 ] observed that placement of two cross distal interlocking screws ( with or without extra engagement screws ) was associated with less postoperative personnel casualty of decrease as compared with other distal interlocking screw constructs. however, in this probe multiple different screw constructs were chosen and surgical fixation of the consociate fibula fracture was at the free will of the treating surgeon [ 43 ]. In a prospective randomized clinical trial in patients with tibial quill fractures undergoing intramedullary pinpoint, Kneifel et aluminum. [ 44 ] compared one versus two distal interlocking screws. These authors reported a importantly higher pace of screw failure with one distal engagement screw. With the numbers available no differences with regards to nonunion were found between the two groups [ 44 ]. The placement of proximal interlocking sleep together is typically performed with the use of an aiming jig that is attached to the nail. The distal engagement screws are most normally inserted in a freehand proficiency under fluoroscopic guidance. recently, interpolation of distal tibial interlocking screws using electromagnetic computer assisted steering systems has been suggested ( Fig. 12a – five hundred ) [ 45 – 48 ]. This technique allows for radiation free insertion of distal interlocking sleep together and has demonstrated to be a feasible and accurate method. however, the hardheaded consumption and cost efficiency of this proficiency remains to be seen and will require farther investigation .Fig. 12figure 12 ad placement of distal interlock screws through fluoroscopic imaging ( ab ) versus electromagnetic guidance organization ( cd ) Full size image placement of proximal and distal interlock screws represents a safe surgical step. however, allow awareness of the surrounding anatomic structures is required and the insertion of interlocking screws must be performed in a accurate and soft tissue friendly manner .


Anatomic studies have demonstrated that in particular with placement of proximal medial-to-lateral oblique interlocking screws there remains a risk of common peroneal nerve palsy [ 49 ] . In order to minimize this risk, surgeons should consider drilling for the screw under fluoroscopic guidance with the fluoroscopic image intensifier angled perpendicular to the plane of the drill bit as opposed to standard anteroposterior and lateral views. Surgeons should be aware of the relatively thin cortical bone within the proximal tibia and should be conscientious about the fact that penetration of the far tibial cortex by the drill bit may be difficult to appreciate by tactile feedback. Moreover, the close proximity of the fibular head may obscure the tactile impression and leave the surgeon with the impression of being ‘in the bone’ when in fact the fibular head is penetrated. The screw length should not only be determined by the scaled drill, but also by appropriate depth gauge measurements. Any drilling or screw length measurements past 60 mm should raise the suspicion for posterolateral prominence which may put the common peroneal nerve at risk for injury [ 49 ] .


With regards to placement of distal anterior-to-posterior interlocking screws, Bono et al. [ 50 ] emphasized the close proximity of the anterior neurovascular bundle, the anterior tibial tendon, and the extensor hallucis longus. These authors recommended placement of surgical incision and careful soft tissue dissection in order to protect the surrounding neurovascular structures during interlocking screw placement [ 50 ] .

We therefore propose placement of interlocking screws as an important separate of the intramedullary pinpoint procedure. While transdermal screw placement is typically condom, surgeons need to be mindful of the surrounding soft tissue structures at risk. For most tibial cock fractures two proximal and two distal interlocking screws provide sufficient stability. Proximal and distal one-third tibial fractures may benefit from placement of extra interlacing screws in different planes in decree to increase the stability of the construct ( Fig. 13a – vitamin d ) .Fig. 13figure 13 ad Segmental tibia fault ( ab ) treated with intramedullary nailing with two distal and three proximal interlocking screws. follow-up radiogram ( cd ) prove uneventful mend Full size visualize

Fixation of associated fibula fractures

contemporary pinpoint designs with distal interlocking screw options have expanded the indication of intramedullary tibial nail down to include proximal and distal fractures involving the metaphyseal area. With regards to distal metaphyseal fractures the question remains if an associate distal fibula fracture should be treated with or without surgical fixation. presently, there is no consensus in the literature with regards to this consequence.

In 2006, Egol et aluminum. [ 43 ] reported on 72 distal tibia fractures undergoing intramedullary tibial nail fixation that were associated with a fibula fracture. In 25 cases, surgical fixation of the fibula was performed. In 47 cases, the associate fibula fracture was treated without surgical fixation. The decision for fibula stabilization was at the delicacy of the process surgeon. respective distal interlock screw constructs were used in this analyze ( 2 screws from medial to lateral versus 2 screws placed perpendicular to each other versus total of 3 distal interlocking screws versus only one distal interlocking screw ). The authors reported that loss of reduction was significantly lower in patients receiving fibula stabilization in conjunction with intramedullary tibial nail obsession. In patients undergeoing intramedullary smash fixation without fibula stabilization, a sum of 13 % showed postoperative loss of reduction versus 4 % when tibial complete was performed without fibula stabilization. The authors far reported that two medial to lateral distal interlocking screw seemed to prevent postoperative loss of decrease, but this determination was not statistically meaning. It must be pointed out that in the fibula stabilization group, the authors recorded a significantly higher percentage of patients with the potentially more golden distal lock screw construct ( 2 medial to lateral screws with or without anteroposterior screw ) than in the no fibula stabilization group ( 86 % versus 45 % of fractures ). In addition, it was recorded that the more distal fractures were more probable to receive fibula stabilization. therefore, the results of this investigation did not seem controlled for fracture location, shape of distal interlocking screws, and count of distal interlocking screws [ 43 ]. In a prospective randomized clinical test, Prasad et aluminum. [ 51 ] compared intramedullary tibial nail obsession with fibula obsession versus intramemedullary tibial breeze through fixation without fibula fixation in 60 distal third tibia-fibula fractures. The authors reported better rotational and varus/valgus alignment in patients undergoing fibula fixation in junction with tibial pinpoint. however, the authors besides reported a wound complication rate of 10 % in the fibula fixation group [ 51 ]. We conclude that in distal third gear tibial beam fractures undergoing intramedullary nail fixation, accessory fibula arrested development may allow for achieving and maintaining fracture decrease of the tibia. however, there remains the concern of wind complications from the extra incision in the area of traumatize tissue. We therefore suggest using adjunct fibula fixation cautiously. contemporary tibial nail designs typically provide different options for placement of stable distal mesh prison guard constructs minimizing the risk for postoperative loss of reduction. extra plate obsession of the fibula should be reserved for associated unstable injuries to the ankle joint or when it is felt that anatomic tibial alignment can not be achieved without direct decrease of the consort fibula fracture .

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