Intramedullary nail fixation of tibia shaft fractures is the standard treatment of diaphyseal tibia fractures and has increasingly been used for proximal and distal metaphyseal fractures as reduction techniques, approaches, and implants have evolved. To avoid typical apex anterior deformities in proximal tibia fractures treated with intramedullary nails, an early report of a semiextended positioning and medial parapatellar approach was described.1 More recently, the suprapatellar approach has evolved with specialized instruments to protect the intraarticular anatomy during the procedure.2 Kubiak et al3 described an alternative approach that allowed for the same leg position on the operating table without the need for specialized instruments, using either a medial or lateral parapatellar, extraarticular approach. Both approaches have demonstrated excellent results regarding knee pain and healing.4,5 The advantages of semiextended position go beyond the ability to avoid deformity in proximal tibia fractures treated with intramedullary nails. They include familiarity of positioning for operating room personnel, ease of fluoroscopic imaging, and stability of the limb to aid in obtaining and maintaining reduction. The ability to maintain this standard position of the limb allows for fluoroscopic imaging in the appropriate planes without extremes of C-arm angulation. Furthermore, the ability to remain in one position through the procedure decreases opportunities to lose reduction with manipulation of the limb before completion of fixation. This video (see Video, Supplemental Digital Content 1, http://links.lww.com/JOT/A384) demonstrates a distal tibia fracture treated with an intramedullary nail placed in the semiextended position through an extraarticular, lateral parapatellar approach.
A 39-year-old woman presented after a fall from a height with a painful, deformed left leg. There were moderate swelling and ecchymosis, a normal neurovascular examination, and no evidence of compartment syndrome. There were no open wounds. Radiographs of the tibia demonstrated a spiral-type fracture of the distal third of the tibia and fibula. No intraarticular extension of the tibia fracture was seen on preoperative ankle radiographs. The patient was indicated for reduction and fixation of the tibia with an intramedullary nail, with possible reduction and fixation of the fibula pending a stress examination of the ankle joint after fixation of the tibia.
The patient is positioned supine on a radiolucent table with a bump under the ipsilateral hip and a foam ramp under the leg. Additional knee flexion to approximately 30 degrees is achieved using a roll of towels. A 6-cm incision is made over the lateral border of the patellar tendon and patella and taken sharply through the skin, subcutaneous tissue, and the retinaculum. Blunt dissection is taken behind the patellar tendon and the patella displaced medially. Additional patellar displacement can be achieved by extending the proximal lateral retinacular incision. The start point can be established with a guide wire or an awl (demonstrated in this video) and confirmed with biplanar fluoroscopy. After opening the insertion site with an awl or a rigid reamer, the ball tip guide wire is placed through the opening portal and into the tibial canal to the level of the fracture. Indirect or percutaneous direct (demonstrated in this video) reduction can be obtained and is maintained after passage of the ball tip guide wire through reaming and nail insertion. After the nail is inserted, locking bolt placement using the perfect-circle radiographic technique is performed with the leg in the same position, avoiding potential displacement of the fracture with changes in the position. Proximal locking bolts are placed through the outrigger. Ankle stress examination with fluoroscopy demonstrates stability of the mortise, despite the fibula fracture and newly noted minimally displaced fracture in the Chaput tubercle. Examination of the proximal approach confirms no violation of the knee capsule. The retinaculum is repaired, and the remaining wounds are closed in the standard fashion. Postoperative treatment includes variations in splint application for soft tissue rest as needed in the immediate postoperative period and limitation in weight bearing for fractures with extension into the ankle (as seen in this case). For standard diaphyseal tibia fractures treated with the same technique, immediate weight bearing on the injured extremity and unlimited knee and ankle range of motion are allowed.
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