Suprapatellar nailing effective for tibial shaft, periarticular fractures

tibial shaft fractures have an incidence of 16.9 per 100,000 people per year. Men aged 10 to 20 years tend to sustain these fractures, whereas women aged 20 to 30 years tend to sustain these injuries. The mechanism of injury include low-energy twisting injuries or high-octane trauma which portend a high risk of consociate cushy tissue injury due to the hypodermic localization of the tibia. treatment options are largely dictated by integrity of the voiced tissue envelope and location of the fracture .
The standard of concern of diaphyseal tibia fractures has become intramedullary complete, either infrapatellar pinpoint or suprapatellar complete. traditionally, the indication for suprapatellar pinpoint was proximal third or metaphyseal fractures because the suprapatellar approach path helped neutralize the deform forces ( patellar tendon, gastrocnemius, pes anserinus and anterior compartment muscular structure ) that would normally cause the fracture to fall into valgus and procurvatum. Joerg Franke, MD, and his colleagues cite that the indications for suprapatellar pinpoint have expanded to open fractures with soft tissue wrong to the infrapatellar region, flexure deficit of the stifle roast, patella baja, ossification of the patellar tendon, indulgent tissue that has undergo flap coverage, and heart or rake vessel damage, which can be worsened by the academic degree of arm manipulation that the infrapatellar technique much requires. additionally, Heather A Vallier, MD, and her colleagues reported that arrested development of distal-third tibial quill fractures with plates and screws results in less malalignment than intramedullary collar. however, Frank R. Avilucea, MD, and his colleagues showed suprapatellar complete resulted in malalignment that exceeded 5° in merely 3.8 % of patients in their series, arguing that the suprapatellar proficiency can improve outcomes in these fracture patterns, american samoa well. As such, it immediately seems the course is moving toward suprapatellar nail down as the prefer method acting due to ease of put and still of fluoroscopy.

Surgical technique

In this case, a 60-year-old man, presenting as a pedestrian who was struck, sustained a close segmental tibial spear fracture ( Figure 1 ). He was brought to the OR and placed on a radiolucent Jackson table. A rotary actuator ( Bone Foam ) is placed under the surgical limb ( Figure 2 ). The patient is prepped and draped in convention sterile manner. The C-arm is positioned on the contralateral side of the injured limb. Two blue towels are rolled up and placed under the knee to far facilitate a begin point ( Figure 3 ) .

Figure 1. Preoperative AP and lateral images show the left tibia and fibula of a 60-year-old man who was struck as a pedestrian. These demonstrate a segmental tibial shaft fracture with concomitant transverse fibula fracture. Figure 2. The patient is placed on a radiolucent Jackson table with a Ramp Leg Elevater (Bone Foam) positioner under the operative leg. The C-arm is positioned opposite the operative limb. Figure 3. The patient is prepped and draped in sterile fashion.
source : Richard S. Yoon, MD
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A 4-cm incision is made two fingerbreadths proximal to the superior pole of the patella ( Figure 4 ). astute dissection is taken down to the level of the quadriceps tendon and a subsequent humble medial parapatellar arthrotomy is made. The guidewire is placed equitable lateral to the medial tibial spine on the anteroposterior ( AP ) view and anterior to the meniscus on the lateral view ( Figure 5 ). We have found that if the tip of the guidewire is at the grade of the lateral tibial tableland on the AP horizon, this typically correlates to the allow depart point on the lateral pass view, as well. however, it is silent imperative to obtain extraneous views to confirm guidewire placement .

Reaming and fracture reduction

once guidewire placement is confirmed, the intra-articular easy tissue defender is placed and two wires are inserted through the soft tissue defender to maintain its military position. The opening reamer is then inserted and opening reaming takes place. subsequently, attention is paid to decrease of the fracture. In this shell, a little jab incision is made and a big luff reduction clamp is used to maintain the reduction ( Figure 6 ). The ball-tipped guidewire is then inserted down to the level of the physeal scar at the ankle. consecutive ream is then done astir to 1.5 mm more than the hope pinpoint size. After reaming is complete, the nail is attached to the jig and inserted over the ball-tipped guidewire. The ball-tipped guidewire is subsequently removed. Two proximal locking screws are placed through the jig. Two or three distal locking screws are placed via the arrant lap technique ( Figure 7 ) .

Figure 4. A 4-cm incision is made two fingerbreadths proximal to the superior pole of the patella. Figure 5. Intraoperative fluoroscopy demonstrates the appropriate starting point on the AP and lateral radiograph (a). If the tip of the guidewire is at the level of the lateral joint line on the AP radiograph, this correlates with the appropriate starting point on the lateral image (b). Figure 6. Intraoperative fluoroscopy shows maintenance of the reduction with a large, pointed reduction clamp and insertion of the ball-tipped guidewire.Figure 7. Radiographs show tibial nail placement.

After the nail down is successfully placed, attention should be paid to closure. In particular, it is imperative to thoroughly irrigate the arthrotomy site. additionally, we place 1 milligram to 2 mg vancomycin powder into the arthrotomy anterior to closure. In this character, we use # 1 Vicryl suture ( Ethicon Inc. ) for arthrotomy closure followed by 2.0 Vicryl suture ( Ethicon ) for hypodermic closure and 3.0 nylon suture for skin settlement.

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Special considerations

With respect to distal-third tibial diaphysis fractures, our protocol is to obtain preoperative CT scans to investigate whether a attendant posterior malleolus fracture is present. If a back tooth malleolus fracture does exist, one or two anterior to posterior cannulated screws are inserted anterior to the interpolation of the pinpoint. K-wires are placed under fluoroscopic steering and their situation is confirmed on orthogonal views. partially threaded 4-mm cannulate screws are placed over the K-wires. Once fixed, a criterion tibial nail down proficiency is used as previously outlined ( Figure 8 ) .
The suprapatellar collar technique can besides be used for periarticular fractures. In cases where there are ipsilateral tibial tableland and tibial shaft fractures, the tableland is reduced and fixed initially with unicortical screws placed through the plate to accommodate the nail. When suprapatellar nail down is performed, the preliminarily fixed fracture undergoes less handling during smash interpolation than if traditional infrapatellar nail down is used. Once the complete is successfully inserted, bicortical screws can be placed to fill the plate around the collar ( Figure 9 ) .

Figure 8. Intraoperative fluoroscopy and postoperative AP, mortise and lateral ankle views demonstrate how a partially threaded cannulated screw is placed for posterior malleolus fixation.Figure 9. Intraoperative fluoroscopy shows the preliminary plate fixation with K-wires and unicortical screws as the tibial nail is being inserted, followed by completed screw placement through the plate once the nail has been placed.


Liqing Yang and colleagues performed a systematic review and meta-analysis that compared suprapatellar and infrapatellar intramedullary pinpoint for tibial cheat fractures. Their learn showed that suprapatellar intramedullary collar trended towards reduced total blood loss, reduced fluoroscopy times, improved result scores and less postoperative stifle trouble compared to infrapatellar intramedullary complete. Roy W. Sanders, MD, and his colleagues performed a prospective sketch of outcomes of suprapatellar pinpoint which showed that, at 1 year postoperatively, no affected role complained of front tooth knee pain at either the patellofemoral site or anterior proximal tibia web site. additionally, alone two of 15 patients had grade II chondromalacia at the trochlea immediately postoperatively. however, the chondromalacia did not correspond with MRI or clinical findings at 1 year .
Suprapatellar breeze through is a versatile proficiency that can be used to treat most tibial shaft fractures, including periarticular fractures, with good outcomes. We note, however, that we continue to use infrapatellar smash in rewrite and infection cases, and therefore preach that orthopedic surgeons gain a level of familiarity with both techniques.

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Disclosures: Liporace reports he is a adviser for and receives royalties from Zimmer Biomet, DePuy Synthes and Wright Medical, and he is a adviser for Conventus Orthopaedics. Yoon reports he is a adviser for Arthrex, DePuy Synthes, Wright Medical and OrthoXel. Jankowski reports no relevant fiscal disclosures .

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Category : Nail Technique

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