Orthobullets Technique Guides cover data that is “ not testable ” on ABOS Part I

  • approach
    • flex knee over radiolucent triangle and mark out inferior pole of patella, borders of patellar tendon, joint line, tibial tubercle 
    • make incision from inferior pole of patella distally 2.5cm towards tibial tubercle along medial 1/3 of patellar tendon
    • spread down to dissect paratenon, identify medial edge of patellar tendon and incise
    • retract patellar tendon laterally and spread down to guidewire starting point
    • insert self-retaining retractor such as a Gelpi to maintain access
  • Guidewire interpolation
    • guidepin start point
      • just medial to the lateral tibial spine on the AP radiograph
      • on anterior cortical downslope on lateral view
    • guidepin should be placed parallel with canal on AP view and just posterior to parallel on lateral view
    • use soft tissue protector over guidewire
    • use cannulated starting point reamer to open canal (drill to metaphyseal bone)
    • remove starting pin and reamer, place balltip guidewire in canal with T-handle
      • place gentle bend at tip of wire, manually push in to distal aspect of fracture site on C-arm
  • fracture Reduction
    • reduce fracture by pulling traction over triangle
      • can use small blue towel bump behind leg as a bump
      • use mallet to hold pressure over fracture site
      • can use intramedullary finger reduction tool and/or pointed reduction clamps through skin incisions 
    • once fracture reduced, manually push guidewire past fracture site to distal physeal scar
      • check biplanar imaging to ensure wire is in canal
    • measure nail length with ruler
  • Traveling grip
    • if working alone or with untrained assistant, or if reduction assistance is needed, apply traveling “box” traction before knee incision
    • can use femoral distractor over pins as an alternate to external fixator bars
    • insert pins through posterior distal tibia and posterior proximal tibia (just anterior to fibular head but in posterior proximal tibia)
  • Reaming
    • start with size 9mm reamer, then ream up 0.5-1.0mm with each reamer
    • push down through starting hole into bone before starting reamer
      • this prevents eccentric reaming of your starting point
    • can use step stool to get better body position for reaming if needed
    • check chatter from reamer feedback and diaphyseal fit on C-arm imaging
    • minimal to no reaming at fracture site to minimize eccentric reaming
    • ream 1.0 above size of final nail (i.e. size 12mm reamer head for size 11mm nail)
    • ream on full speed, slowly and deliberately, don’t stop reamer in canal (avoids reamer head from becoming incarcerated)
    • if a distal fracture, don’t ream the distal tibia unless the guidewire is in perfect position
  • Blocking Screws
    • if wreath or sagittal malalignment is noted, blocking screws are placed on the concave shape of the deformity
      • most normally placed back tooth or lateral pass to the guide telegram in the proximal segment in proximal 1/3 fractures
    • these screws serve as a pseudo-cortex to guide the nail
    • these screws also serve to increase construct stiffness
  • Nail Insertion
    • build nail on backtable and make sure targeting guide lines up with holes in nail
    • insert nail over guidewire and push into place manually as much as possible
      • advance to fracture site and minimize mallet use at fracture site to minimize iatrogenic comminution
      • insert nail fully and check lateral C-arm view at the knee to ensure the nail is sunk at or below the edge of the bone
      • rotation of the nail should align with 2nd metatarsal
    • if compression is needed across fracture site, insert distal interlocking screws via perfect circles technique then backslap distal fragment into proximal fragment
      • must sink nail into proximal segment enough to allow backslapping
    • remove guidewire before placing interlocking screws
  • Proximal Interlocking Screws
    • attach proximal targeting guide and mark skin with triple sleeves for 2-3 static holes
    • use a 15 blade through skin, spread down to bone with hemostat, place trochar of sleeve on bone
    • remove inner sleeve then drill through 1st cortex and nail
      • when hitting 2nd cortex, stop and measure, call out length, then finish 2nd cortex (2nd cortex adds 2-5mm)
      • remove inner sleeve and insert screw
      • be careful not to over tighten screws as they can sink into bone easily in metaphyseal bone
    • repeat process above for placement of other interlocking screws if indicated
    • can lock screws proximally into nail if the instrumentation allows
    • remove targeting guide and jig from nail
  • distal Interlocking Screws
    • bring the knee into full extension and lay entire leg on sterile bumps
    • move to distal tibia and get perfect circles of interlock screws
      • ensure no rotation of the distal tibia is done while getting the fluoroscopic views (move the C-arm, not the leg)
      • magnification of fluoro (x2) can be used if desired, but is not necessary
    • use a 15 blade scalpel to locate the nailhole on medial distal tibia, and incise through skin
    • spread down to bone with hemostat
    • place drill in hole, then center drill parallel to xray beam
      • drill toward center of C-arm beam
      • do not stop drill when bit at nail unless progress halted by eccentric drilling
      • if drilling is off, take drill off bit and leave bit in drilled hole
        • recenter the bit on fluoroscopy and use a mallet to drive it across the nail holes
    • measure the depth with a depth gauge or with calibrated drill bit
    • remove drill quickly and insert screw
    • repeat above process for 2nd distal interlocking screw
      • have more freedom to move the limb for fluoroscopy after first screw placed
  • Confirm Nail Position and Extremity Check
    • obtain biplanar fluroscopic images of the proximal, middle, and distal tibia
    • check limb length, rotation, alignment, and perform a knee ligamentous examination
informant : https://nailcenter.us
Category : Nail Technique

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