Surgical Technique

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 mechanisms of injury include low-energy twisting injuries or high-energy trauma which portend a high risk of associated soft tissue injury due to the subcutaneous location of the tibia. Treatment options are largely dictated by integrity of the soft tissue envelope and location of the fracture.

The standard of care of diaphyseal tibia fractures has become intramedullary nailing, either infrapatellar nailing or suprapatellar nailing. Traditionally, the indication for suprapatellar nailing was proximal third or metaphyseal fractures because the suprapatellar approach helped neutralize the deforming forces (patellar tendon, gastrocnemius, pes anserinus and anterior compartment musculature) that would normally cause the fracture to fall into valgus and procurvatum. Joerg Franke, MD, and his colleagues cite that the indications for suprapatellar nailing have expanded to open fractures with soft tissue damage to the infrapatellar region, flexion deficit of the knee joint, patella baja, ossification of the patellar tendon, soft tissue that has undergone flap coverage, and nerve or blood vessel damage, which can be worsened by the degree of limb manipulation that the infrapatellar technique often requires. Additionally, Heather A Vallier, MD, and her colleagues reported that fixation of distal-third tibial shaft fractures with plates and screws results in less malalignment than intramedullary nailing. However, Frank R. Avilucea, MD, and his colleagues showed suprapatellar nailing resulted in malalignment that exceeded 5° in only 3.8% of patients in their series, arguing that the suprapatellar technique can improve outcomes in these fracture patterns, as well. As such, it now seems the trend is moving toward suprapatellar nailing as the preferred method due to ease of positioning and ease of fluoroscopy.

Surgical technique

In this case, a 60-year-old man, presenting as a pedestrian who was struck, sustained a closed segmental tibial shaft fracture (Figure 1). He was brought to the OR and placed on a radiolucent Jackson table. A positioner (Bone Foam) is placed under the operative limb (Figure 2). The patient is prepped and draped in normal sterile fashion. 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 further facilitate a starting 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

A 4-cm incision is made two fingerbreadths proximal to the superior pole of the patella (Figure 4). Sharp dissection is taken down to the level of the quadriceps tendon and a subsequent small medial parapatellar arthrotomy is made. The guidewire is placed just 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 level of the lateral tibial plateau on the AP view, this typically correlates to the appropriate starting point on the lateral view, as well. However, it is still imperative to obtain orthogonal views to confirm guidewire placement.

Reaming and fracture reduction

Once guidewire placement is confirmed, the intra-articular soft tissue protector is placed and two wires are inserted through the soft tissue protector to maintain its position. The opening reamer is then inserted and opening reaming takes place. Subsequently, attention is paid to reduction of the fracture. In this case, a small stab incision is made and a large pointed 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. Sequential reaming is then done up to 1.5 mm more than the desired nail 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 perfect circle 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 is successfully placed, attention should be paid to closure. In particular, it is imperative to thoroughly irrigate the arthrotomy site. Additionally, we place 1 mg to 2 mg vancomycin powder into the arthrotomy prior to closure. In this case, we use #1 Vicryl suture (Ethicon Inc.) for arthrotomy closure followed by 2.0 Vicryl suture (Ethicon) for subcutaneous closure and 3.0 nylon suture for skin closure.

Special considerations

With regard to distal-third tibial shaft fractures, our protocol is to obtain preoperative CT scans to investigate whether a concomitant posterior malleolus fracture is present. If a posterior malleolus fracture does exist, one or two anterior to posterior cannulated screws are inserted prior to the insertion of the nail. K-wires are placed under fluoroscopic guidance and their position is confirmed on orthogonal views. Partially threaded 4-mm cannulated screws are placed over the K-wires. Once fixed, a standard tibial nailing technique is used as previously outlined (Figure 8).

The suprapatellar nailing technique can also be used for periarticular fractures. In cases where there are ipsilateral tibial plateau and tibial shaft fractures, the plateau is reduced and fixed initially with unicortical screws placed through the plate to accommodate the nail. When suprapatellar nailing is performed, the preliminarily fixed fracture undergoes less manipulation during nail insertion than if traditional infrapatellar nailing is used. Once the nail is successfully inserted, bicortical screws can be placed to fill the plate around the nail (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.

Discussion

Liqing Yang and colleagues performed a systematic review and meta-analysis that compared suprapatellar and infrapatellar intramedullary nailing for tibial shaft fractures. Their study showed that suprapatellar intramedullary nailing trended towards reduced total blood loss, reduced fluoroscopy times, improved outcome scores and less postoperative knee pain compared to infrapatellar intramedullary nailing. Roy W. Sanders, MD, and his colleagues performed a prospective study of outcomes of suprapatellar nailing which showed that, at 1 year postoperatively, no patient complained of anterior knee pain at either the patellofemoral site or anterior proximal tibia site. Additionally, only 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 nailing is a versatile technique 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 nailing in revision and infection cases, and therefore advocate that orthopedic surgeons gain a level of familiarity with both techniques.

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

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 mechanisms of injury include low-energy twisting injuries or high-energy trauma which portend a high risk of associated soft tissue injury due to the subcutaneous location of the tibia. Treatment options are largely dictated by integrity of the soft tissue envelope and location of the fracture.

The standard of care of diaphyseal tibia fractures has become intramedullary nailing, either infrapatellar nailing or suprapatellar nailing. Traditionally, the indication for suprapatellar nailing was proximal third or metaphyseal fractures because the suprapatellar approach helped neutralize the deforming forces (patellar tendon, gastrocnemius, pes anserinus and anterior compartment musculature) that would normally cause the fracture to fall into valgus and procurvatum. Joerg Franke, MD, and his colleagues cite that the indications for suprapatellar nailing have expanded to open fractures with soft tissue damage to the infrapatellar region, flexion deficit of the knee joint, patella baja, ossification of the patellar tendon, soft tissue that has undergone flap coverage, and nerve or blood vessel damage, which can be worsened by the degree of limb manipulation that the infrapatellar technique often requires. Additionally, Heather A Vallier, MD, and her colleagues reported that fixation of distal-third tibial shaft fractures with plates and screws results in less malalignment than intramedullary nailing. However, Frank R. Avilucea, MD, and his colleagues showed suprapatellar nailing resulted in malalignment that exceeded 5° in only 3.8% of patients in their series, arguing that the suprapatellar technique can improve outcomes in these fracture patterns, as well. As such, it now seems the trend is moving toward suprapatellar nailing as the preferred method due to ease of positioning and ease of fluoroscopy.

Surgical technique

In this case, a 60-year-old man, presenting as a pedestrian who was struck, sustained a closed segmental tibial shaft fracture (Figure 1). He was brought to the OR and placed on a radiolucent Jackson table. A positioner (Bone Foam) is placed under the operative limb (Figure 2). The patient is prepped and draped in normal sterile fashion. 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 further facilitate a starting 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). Sharp dissection is taken down to the level of the quadriceps tendon and a subsequent small medial parapatellar arthrotomy is made. The guidewire is placed just 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 level of the lateral tibial plateau on the AP view, this typically correlates to the appropriate starting point on the lateral view, as well. However, it is still imperative to obtain orthogonal views to confirm guidewire placement.

Reaming and fracture reduction

Once guidewire placement is confirmed, the intra-articular soft tissue protector is placed and two wires are inserted through the soft tissue protector to maintain its position. The opening reamer is then inserted and opening reaming takes place. Subsequently, attention is paid to reduction of the fracture. In this case, a small stab incision is made and a large pointed 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. Sequential reaming is then done up to 1.5 mm more than the desired nail 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 perfect circle 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 is successfully placed, attention should be paid to closure. In particular, it is imperative to thoroughly irrigate the arthrotomy site. Additionally, we place 1 mg to 2 mg vancomycin powder into the arthrotomy prior to closure. In this case, we use #1 Vicryl suture (Ethicon Inc.) for arthrotomy closure followed by 2.0 Vicryl suture (Ethicon) for subcutaneous closure and 3.0 nylon suture for skin closure.

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Special considerations

With regard to distal-third tibial shaft fractures, our protocol is to obtain preoperative CT scans to investigate whether a concomitant posterior malleolus fracture is present. If a posterior malleolus fracture does exist, one or two anterior to posterior cannulated screws are inserted prior to the insertion of the nail. K-wires are placed under fluoroscopic guidance and their position is confirmed on orthogonal views. Partially threaded 4-mm cannulated screws are placed over the K-wires. Once fixed, a standard tibial nailing technique is used as previously outlined (Figure 8).

The suprapatellar nailing technique can also be used for periarticular fractures. In cases where there are ipsilateral tibial plateau and tibial shaft fractures, the plateau is reduced and fixed initially with unicortical screws placed through the plate to accommodate the nail. When suprapatellar nailing is performed, the preliminarily fixed fracture undergoes less manipulation during nail insertion than if traditional infrapatellar nailing is used. Once the nail is successfully inserted, bicortical screws can be placed to fill the plate around the nail (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.

Discussion

Liqing Yang and colleagues performed a systematic review and meta-analysis that compared suprapatellar and infrapatellar intramedullary nailing for tibial shaft fractures. Their study showed that suprapatellar intramedullary nailing trended towards reduced total blood loss, reduced fluoroscopy times, improved outcome scores and less postoperative knee pain compared to infrapatellar intramedullary nailing. Roy W. Sanders, MD, and his colleagues performed a prospective study of outcomes of suprapatellar nailing which showed that, at 1 year postoperatively, no patient complained of anterior knee pain at either the patellofemoral site or anterior proximal tibia site. Additionally, only 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 nailing is a versatile technique 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 nailing in revision and infection cases, and therefore advocate that orthopedic surgeons gain a level of familiarity with both techniques.

PAGE BREAK

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