Tibial nailing has been used successfully for many years. The advent of small diameter locking nails has greatly increased its indications.7 Typically, nailing was reserved for fractures that were entirely below the tubercle.1,7 However, little attention has been paid to the techniques of nailing proximal fractures. Henley recently showed that nails designed with the proximal bend located more distally cause fractures to be angulated.3
Most authors recommend at least 90 ° knee flexion for tibial nailing.2,3,5,6 Others believe that having the knee more extended for proximal fractures is beneficial.
The purpose of this study is to describe the use of a semiextended position (range, 15 °-20 ° flexion) to aid in the intraoperative reduction and nailing of proximal fractures. This technique is described, and the reductions in 25 patients are reviewed.
MATERIALS AND METHODS
Over a 24 month period, 30 consecutive patients with proximal tibia fractures were treated by nonreamed, interlocked, intramedullary nailing. Proximal was defined as extension of the fracture line into the proximal ¼ of the tibia. Indications were determined by a standard protocol and included all Grades I to IIIb open fractures and fractures in multiple trauma patients. Isolated tibia fractures in which an adequate reduction could not be maintained in a cast and had been nailed within 5 days of injury were also included.
The average age of the patients was 37 years (range, 16-70 years). There were 19 open fractures: 2 Grade I, 7 Grade II, 6 Grade IIIa, and 4 Grade IIIb. Thirteen of the fractures were segmental and 7 were comminuted (Winquist III, IV). Twenty of the 30 fractures (67%) extended into the metaphysis.
All nailings were performed while the affected leg was on a radiolucent table without traction, as previously described.7 One patient had a compartment syndrome before surgery, which was treated with a 4 compartment fasciotomy. No patient developed a compartment syndrome perioperatively.
The first 5 operations were performed using the authors' standard approach for tibial nailings.7,8 This consisted of a midline incision from the distal patella to the tibial tubercle combined with an incision medial to the patellar tendon. The retinaculum was not divided. Using this method, the knee was flexed to at least 85 ° to obtain direct access to the tibial portal for nail placement. This was accomplished by placing the tibia in a sterile bag over the side of the table or by using a sterile bolster under the thigh. In these patients, it was difficult to control the sagittal alignment of the fracture while flexing the knee to access the portal (Fig 1). This led to the decision of using the semiextended position for the remaining 25 patients.
The leg is positioned in approximately 15 ° flexion with a small bolster under the thigh. More flexion is not necessary and will contribute to anterior angulation at the fracture site.
A midline skin incision is made from the upper pole of the patella to the tibial tubercle. The deep incision is made medial to the patellar tendon and extended through the inferior ⅔ of the medial patellar retinaculum (Fig 2). This allows for lateral subluxation of the patella during the procedure.
The tibial portal, which is located on the superior surface of the bone in the midline, is visualized easily. Lateral subluxation of the patella allows the trochlear groove to be used as a conduit for placement of the awls, as well as for the nail (Fig 3A). A narrow straight awl is used to start the portal, which is then widened using a 9-mm straight awl (Figs 3B-C). It is essential that the direction of the awls be checked with fluoroscopy as they are driven into the tibia. The awls must be directed as anteriorly in the proximal tibia as possible (Fig 3C). When properly positioned, the awl will rest gently on the trochlear groove. This will create a tract for the nail to follow as it is introduced. The proximal bow in the nail will then aid in reducing the fracture as it is terminally seated.
Strict attention also must be paid to the direction of the awls on the anteroposterior image. The fracture will tend to become angulated in the coronal plane. For this reason, the center of the proximal fragment must be the target of the awl, not the tibial crest on the distal fragment. Because the center of the proximal tibia is difficult to determine by palpation, the direction of the awls should be confirmed with fluoroscopy. The awls need not be introduced into the distal fragment for nonreamed nails.
Any malalignment of the tract made with the 9-mm awl will result in the same malalignment of the fracture at the completion of nailing. The portal should not be widened any more than 10 mm because a tight fit of the nail in the proximal fragment will add to stability.
Once the awls have been satisfactorily placed and an appropriate tract exists, the nail is placed. Lateral subluxation of the patella is necessary during nail placement. The nail will aid in obtaining an anatomic reduction (Fig 4). Locking is done proximally and the jig is removed before distal locking, which is performed with the knee fully extended. The arthrotomy should be drained for 24 to 48 hours to prevent hemarthrosis.
For the first 5 patients, whose fractures were nailed while their knees were flexed, the average anterior angulation was 8 ° (range, 5 °-15 °). In the subsequent 25 patients, whose fractures were nailed while their knees were in the semiextended position, no patient had greater than 5 ° anterior angulation. Nineteen of the 25 patients had no anterior angulation. For the entire group, 3 fractures had greater than 5 ° angulation in the coronal plane. Two of these were operated on in the semiextended position. For all patients, the distance from the fracture to the proximal locking screws averaged 24 mm (range, 0-65 mm).
Two patients had fractures that had coronal plane instability after the nail was in place and locked. Both fractures were augmented with external stabilization until sufficient callus prevented motion at the fracture site. One was augmented with a long leg cast for 2 weeks and then a hinged cast brace for 6 weeks. The other, which occurred in a 70-year-old woman, was placed in a hinged brace for a total of 10 weeks. Both fractures were 6 cm from the joint line and 1 had an associated proximal fibula fracture. In both patients, the entrance portal was significantly larger than the final nail diameter.
There were 3 complications specifically related to the semiextended technique. One patient developed a tense, painful hemarthrosis postoperatively. This was treated by aspiration at the bedside on postoperative day 2, followed by an elastic wrap. This patient had no further sequelae. (He did not have a drain placed at the time of the surgery, and it is now the authors' standard practice to drain the arthrotomy.) Two other patients treated early in the series sustained minor abrasions of the trochlear groove during placement of the nail. In both cases, the junction between the nail and the jig was the offending region. These abrasions were approximately 1 to 2 mm wide and 0.5 cm long; they were not full thickness. The authors now increase the flexion slightly during terminal seating of the nail if there is a tight fit between the groove and the nail to avoid this problem. No abrasions occurred during the portal placement because the straight awls were smooth. No patellofemoral pain was exhibited by these 2 patients during their treatment periods of 18 and 22 months.
Proximal tibia fractures are difficult to treat with intramedullary nails for several reasons. The nail is significantly smaller than the area within the proximal fragment. This makes alignment in both the sagittal and coronal planes dependent on the operative reduction. In shaft fractures, particularly in the isthmal area, placement of an intramedullary nail almost guarantees an acceptable reduction. This is not true for proximal fractures where a small angulation can be accentuated by the nail as it is placed. In particular, many surgeons perform tibial nailing in the 90 °-90 ° position.2,3,5 This position places tension on the patellar tendon and a resultant extension force on the proximal fragment. This force can result in anterior angulation at the fracture site, as was seen in the 5 fractures nailed while the knee was in flexion (Fig 1).
The purpose of this article was to describe a technique that can aid in avoiding malreductions and make nailing of proximal tibia fractures less technically demanding. The semiextended position greatly facilitated the authors' ability to neutralize the extension force of the patellar tendon. It also made anteroposterior imaging of the proximal fragment during portal placement much easier. The reductions were better using this technique, and subjectively, the procedures were easier to perform. Less manipulation of the leg was needed when obtaining images and during placement of the nail.
There are, however, several pitfalls which must be avoided. First, care must be taken to check portal placement in both planes. Straight awls are helpful in establishing an appropriately directed tract. The authors caution against the use of curved awls because they may impinge on the trochlear groove and cause significant cartilaginous damage. Curved awls also cannot establish a long enough tract to direct the nail during placement.
Second, care must be taken to avoid damage to the trochlear groove during nail insertion. As the nail jig interface approaches the groove, if the fit is tight, knee flexion should be increased just enough to relieve the pressure. At this point in the procedure, the reduction should not be lost by a slight increase in flexion because the nail is well across the fracture site. Damage to the trochlear groove occurred in 2 of the fractures described earlier. These patients have had no complaints to date, but the long term effects of these small cartilaginous injuries will require longer followup.
Third, the portal should not be made larger than the proximal end of the nail. A tight fit of the nail in the proximal fragment adds to stability. The 2 fractures in the present series in which supplemental external support was necessary may have resulted, in part, because of a large portal. Another possibility is that external support may be needed in particularly weak or osteopenic bone. One of these patients had an associated proximal fibula fracture which further destabilized his leg. This also may have had a role in the instability seen in this patient, although other patients with this fracture configuration did not show any instability.
Lastly, as shown by Henley et al, a nail with a very proximal bend should be used for proximal fractures.4 More distal bends in the nail will cause malreduction at the fracture site. Additionally, regardless of the fracture configuration, proximal locking is necessary.
Use of the semiextended position with a partial medial parapatellar arthrotomy enhanced the authors' ability to nail these fractures. This approach was effective, reproducible, and had a low complication rate. This technique is recommended for the nailing of proximal tibia fractures.
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8. Tornetta III P, Barbera C: Severe heterotopic bone formation in the knee after tibial intramedullary nailing. J Orthop Trauma 6:113-115, 1992.