Tibial Intramedullary Nail Fixation Technique

Intramedullary nail fixation remains the treatment of choice for unstable and displaced tibial stem fractures in adults. The goal of surgical treatment is to restore length, alignment and rotation of the tibia and to achieve fracture healing. The advantages of intramedullary nailing are minimal surgical trauma and appropriate preservation of the blood supply to the fracture. In addition, intramedullary nailing of the tibia provides appropriate biomechanical fracture stability and acts as a load-sharing device allowing early postoperative mobilization. Advances in intramedullary nail design and reduction techniques have expanded the indications for intramedullary nail fixation to include proximal tibia and lower middle third fractures.

To this day, closed reduction intramedullary nail fixation of tibial fractures has become a common procedure for trauma orthopedic surgeons. Despite the popularity of intramedullary nail fixation for displaced tibial stem fractures, it remains challenging and has multiple potential complications. Surgical techniques continue to evolve. The purpose of this article is to describe current concepts in intramedullary nail fixation of tibial stem fractures and to summarize recent advances in the field.

一. Initial assessment and inspection

In younger patients, tibial stem fractures are often the result of high-energy injuries, and patients must be evaluated for associated trauma according to the Advanced Trauma Life Support (ATLS) guidelines. Evaluate surrounding skin and soft tissue injuries such as fracture blisters, skin abrasions, burns, ecchymosis, or skin elevations; clarify whether the fracture is open, and if so treat with tetanus and antibiotics; and perform a thorough neurovascular examination and document the above. Evaluate the occurrence of osteofascial compartment syndrome and perform a series of clinical examinations in these patients.

Recent studies have shown that the incidence of osteofascial compartment syndrome following tibial tuberosity fractures may be as high as 11.5 %. In particular, younger patient groups are more likely to develop osteofascial compartment syndrome. The diagnosis of osteofascial compartment syndrome should be based on clinical findings, including severe pain, neurovascular changes, swelling of the myofascial compartment, and increased pain from passive toe extension. Therefore, osteofascial compartment syndrome remains a clinical diagnosis and thorough documentation of the clinical examination is essential. Pressure within the myofascial compartment can be measured by means of a pressure needle (Figure 1) as a complementary examination method to the specialty exam.

Figure 1. Measurement of pressure in the interosseous septum by means of a pressure needle

To obtain reliable data, intrafascial pressures should be measured in the four myofascial compartments and at different locations within each myofascial compartment. Studies in the literature suggest that a pressure difference of less than 30 mmHg (diastolic pressure minus fascial compartment pressure) indicates a fascial compartment syndrome. Diastolic pressure usually decreases during surgery, and preoperative diastolic pressure should be taken into account when calculating the differential pressure.

Recent studies have shown that intrafascial pressure monitoring is a potentially useful tool for the diagnosis of acute fascial compartment syndrome, with a sensitivity of 94 % and a specificity of 98 %. However, given the potentially devastating consequences of the compartment syndrome, the diagnosis of compartment syndrome should be based on clinical findings, and interosseous compartment pressure measurements should be used in special circumstances, such as when the patient is injured or when clinical data points are unclear.

Imaging evaluation should include standard orthopantomograms and lateral views of the injured tibia and radiographs of the adjacent knee and ankle joints, which are further evaluated using computed tomography (CT). Similarly, a CT scan of the ankle may be necessary to visualize fracture lines extending to the tibial plateau and associated noncontiguous ankle injuries

二. Clinical pitfalls

A high percentage of fractures of the lower middle third of the tibia with ankle fractures have been reported. Using conventional CT scans, 43 % of fractures of the middle and lower third of the tibia were accompanied by ankle fractures, the majority of which required surgical treatment. The most common type of fracture was a spiral fracture of the lower middle third of the distal tibia associated with a slightly or non-displaced posterior ankle fracture (Figure 2). Due to the small displacement of the associated ankle fracture, only 45 % of injuries can be detected on plain ankle radiographs. Therefore, routine CT scans of the ankle should be highly emphasized when a lower middle tibia fracture is present (Fig. 3).

Figure 2.A-F Spiral fracture of the lower middle third of the right tibia (A, B) Preoperative radiographs of the ankle show normal (C). Intraoperative C-arm fluoroscopy shows a nondisplaced fracture of the posterior ankle (D) Postoperative radiographs after surgical fixation (E-F) show smooth healing of the tibial and ankle fractures

Figure 3. A-F Spiral fracture of the middle and lower third of the left tibia (A-B) preoperative radiographs; (C-D) preoperative CT scans showing a nondisplaced posterior malleolar fracture; (E-F) showing uneventful healing of the tibia and malleolar fracture

三. Surgical methods

01. Tibial Needle Entry Point

Establishing an accurate entry point plays a crucial role and many studies in the literature have provided important information on the anatomical location of the ideal entry point for intramedullary nailing of tibial fractures. These studies have shown that the ideal pinning point is located at the anterior margin of the tibial plateau and just medial to the lateral tibial spur. A safety zone with a width of 22.9 mm ± 8.9 mm, which does not cause damage to adjacent joint structures, was also reported. Traditionally, the starting point for intramedullary nail fixation of tibial stem fractures has been established through an infrapatellar approach, either by splitting the patellar tendon (transpatellar approach) or by stripping part of the patellar tendon stop (paratendinous approach).

Semi-extension intramedullary nailing has attracted considerable attention in the recent orthopedic literature, and Tornetta and Collins suggest using a medial parapatellar approach for internal fixation of the nail in the semi-extension position to avoid protrusion of the apex of the intramedullary nail into the anterior tibial cortex.3 The use of a medial parapatellar approach for intramedullary nailing in the semi-extension position is also recommended. The use of a suprapatellar approach for tibial intramedullary nailing and insertion of the intramedullary nail through the patellofemoral joint in the semi-extended position is recommended.

The procedure is performed with the knee flexed at approximately 15-20 degrees, and a longitudinal incision of approximately 3 centimeters is made approximately one to two finger widths above the patella. The quadriceps tendon is split in a longitudinal fashion and blunt dissection is performed into the patellofemoral joint. A blunt socket is inserted through the patellofemoral joint to create an entry point at the junction of the proximal anterior tibial cortex and the articular surface (Figure 4).

Figure 4. a-b Intraoperative photographs of (a) splitting the quadriceps tendon and inserting the trocar through the patellofemoral joint to the tibial entry point; (b) intraoperative lateral view of the entry point

A 3.2 mm drill bit is used to determine the starting needle point under C-arm guidance. A perforated socket is provided to fine-tune the entry and exit points. The remaining surgical procedures including reaming and tibial nail insertion are performed through the socket.

POTENTIAL ADVANTAGES: The semi-extended leg position may aid in fracture repositioning, especially in fractures with a typical proximal third of the tibia and angled forward. , The semi-extended position may eliminate tension on the quadriceps muscle and aid in fracture repositioning. , The semi-extended position suprapatellar approach may also be an alternative to the traditional infrapatellar approach (Figure 5).

Figure 5. Intraoperative photograph showing soft tissue injury in the infrapatellar region as an indication for a suprapatellar approach in a semi-extended position.

Studies have shown that the suprapatellar approach to tibial intramedullary nailing in the semi-extended position is a safe and effective surgical technique. Future clinical trials are needed to further investigate the advantages and disadvantages of suprapatellar approach intramedullary nailing and to evaluate the long-term outcomes associated with this technique.

02. Reset technology

Placement of a tibial intramedullary nail alone does not result in adequate fracture reduction; proper fracture reduction must be maintained throughout the reaming process and intramedullary nail placement. The application of manual traction alone may not always achieve anatomic reduction of the fracture by itself. This article will describe a variety of closed, minimally invasive, and open reduction maneuvers.

-Closed reset technique tips

Closed reduction maneuvers can be accomplished with a reduction tool such as the F-fracture reducer, an F-shaped radiographically transmissible reduction device that corrects for inversion/exversion angles as well as medial/lateral translation (Fig. 6).

Fig. 6. F-shaped fracture reducer cited in surgery

However, the device can place significant stress on the soft tissues, and prolonged use of this resetting device should be avoided. Reduction forceps can also be placed percutaneously, as in the case of spiral and oblique fractures. These tools can be applied in a soft-tissue friendly manner through small incisions (Figure 7).

Figure 7. Percutaneous clamping to reset a tibial fracture

The type of clamp and the location of the surgical incision should be chosen based on a strategy to minimize long-term damage to soft tissues from clamp placement (Figure 8).

Fig. 8. Pointed repositioning forceps to reset tibial fracture

Retractors are also one of the common resetting tools used to restore length to the tibia. They are usually placed medially and away from the location where the intramedullary nail needs to be placed. Proximal traction pins can be placed to mimic the proximal blocking screw position, which allows for easier reduction of the fracture once the intramedullary nail is in.

In some cases, closed and minimally invasive reduction techniques are still insufficient to obtain anatomic reduction. In such cases, incisional reduction techniques should be considered with careful management of the surrounding soft tissues. Potential disadvantages of open reduction techniques include additional surgical trauma, which may increase the risk of surgical site infection. In addition, additional stripping of the blood supply to the fracture site may increase the risk of postoperative fracture nonunion.

-Technical Skills for Incision and Repositioning

Incisional reduction maneuvers permit not only surgical reduction forceps placed in the proper position, but also the application of small or miniature splints at the fracture site to maintain fracture reduction during intramedullary nailing procedures.

Plates are secured to the proximal and distal fracture fragments using monocortical screws. The splint is retained throughout the process of reaming and placement of the intramedullary nail in the tibia. After placement of the intramedullary nail, the plate was removed or left in place to enhance the stability of the fixed structure (Figure 9). By leaving the plate in place, the single cortical screw should be interchanged with the double cortical screw. It should be considered for use in select cases where the tibial stem requires open surgery to achieve acceptable fracture reduction.

Figure 9. Open tibia fracture with severe comminution and bone defect, single cortical fixation with a small splint at the broken end of the fracture after reduction and removal of the splint after intramedullary nail fixation

The purpose of the blocking nail is to narrow the medullary cavity in the metaphyseal region. Blocking nails are placed within the short articular fragment and on the concave side of the deformity prior to intramedullary nail placement. For example, the typical deformity of a fracture of the proximal third of the tibia is characterized by valgus and forward angulation. To correct the valgus deformity, a locking screw can be placed into the lateral portion of the proximal fracture fragment (i.e., the concave side of the deformity) in an anteroposterior direction. The intramedullary nail is guided from the medial side, thereby preventing valgus. Similarly, angulation deformity can be overcome by placing a locking screw medial to lateral to the posterior portion of the proximal block (i.e., the concave side of the deformity) (Figure 10).

Figure 10. assisted reset of tibial fracture by placement of blocking nails

-Medullary expansion

After completing the fracture repositioning, medullary reaming is selected to prepare the bone for intramedullary nail insertion. The ball-ended guidewire is inserted into the tibial marrow cavity and through the fracture site, and the reaming drill is passed over the ball-ended guidewire. The position of the ball-ended guidewire was confirmed under C-arm fluoroscopy to be at the level of the ankle joint, and the guidewire was well-centered on both anteroposterior and lateral views (Figure 11).

Figure 11. shows the position of the guidewire in the medullary cavity on C-arm fluoroscopy in the frontal and lateral positions

The issue of expanded versus non-expanded medulla has been controversial. We believe that most surgeons in North America prefer expanded medullary intramedullary nailing of the tibia to non-expanded. However, both expanded and non-expanded intramedullary nailing can be used as acceptable standard techniques, and good results can be obtained with both methods.

-Locking screw placement

The use of interlocking screws in tibial stem fractures is intended to prevent shortening and malrotation, extending the indications for intramedullary nailing of the tibia to more proximal and distal tibial stem fractures involving the metaphysis. In fractures involving the metaphyseal region, interlocking screws became more important in maintaining axial alignment.

Three proximal interlocking screws significantly improved stability, and angle-stabilized interlocking screws may provide greater stability than conventional interlocking screws, which may allow the same structural stability to be obtained with a smaller number of interlocking screws. Clinical data on the number and configuration of interlocking screws required for internal fixation of the tibia remain limited.

Placement of proximal interlocking screws is usually performed using a scope attached to the intramedullary nail spike. Distal interlocking screws are inserted freehand under fluoroscopic guidance. The use of an electromagnetic computer-assisted guidance system is recommended for insertion of distal tibial interlocking screws (Figure 12). This technique permits radiation-free insertion of distal interlocking screws and has been shown to be a feasible and accurate method.

Figure 12.A-B Locking screws via C-arm perspective; C-D Locking screws via electromagnetic computer-assisted locking

Placement of proximal and distal interlocking screws is a safe surgical procedure and the interlocking screws must be inserted in a precise and soft tissue friendly manner.

Anatomic studies have shown that there is still a risk of peroneal nerve palsy when placing proximal medial to lateral oblique interlocking screws. To minimize this risk, surgeons should consider drilling for the screws under C-arm guidance, with the fluoroscopic angle of the C-arm perpendicular to the plane of the drill bit. Drill penetration into the cortex of the distal tibia may be difficult to perceive by tactile feedback, and the close proximity of the fibular head may obscure the tactile impression and give the surgeon the impression of being “in the bone” when in fact the fibular head has been penetrated. Screw length should be determined not only by a graduated drill but also by appropriate depth gauge measurements. Any drill or screw length measurement greater than 60 mm should raise suspicion of posterolateral protrusion, which may place the common peroneal nerve at risk of injury.

Distal anterior and posterior interlocking screws are placed with attention to the protection of the anterolateral neurovascular bundle, tibialis anterior tendon, and extensor digitorum longus. Although percutaneous screw placement is usually safe, surgeons need to be aware of the risks to surrounding soft tissue structures. For most tibial stem fractures, two proximal and two distal interlocking screws provide adequate stability. Proximal and distal tibial fractures may benefit from the placement of additional interlocking screws in different planes to increase the stability of this structure (Figure 13).

Figure 13. Multiple fractures of the tibia, treated with intramedullary nailing with two distal and three proximal interlocking screws, with subsequent x-rays suggesting fracture healing.

-Fibular Fixation

Contemporary intramedullary nail designs with distal interlocking screws have expanded the indications for intramedullary nailing of the tibia to include proximal and distal fractures involving the metaphyseal region.

Different distal interlocking screw configurations were used in the study (2 screws from medial to lateral versus 2 screws placed perpendicular to each other and a total of 3 distal interlocking screws versus only 1 distal interlocking screw). In patients who underwent fibular fixation and tibial intramedullary nail fixation, the rate of lost reset was significantly lower. A total of 13 % of patients with intramedullary nail fixation without fibular fixation showed postoperative loss of reset, compared with 4 % of patients with tibial nail fixation without fibular fixation.

In another trial comparing the efficacy of tibial intramedullary nail fixation versus fibular fixation and tibial intramedullary nail fixation versus no fibular fixation, patients treated with fibular fixation in combination with tibial nailing showed improvement in rotational and inversion/eversion alignment.

We conclude that adjunctive fibular fixation achieves and maintains tibial fracture reduction in distal one-third tibia fractures undergoing intramedullary nail fixation. However, the problem of wound complications from additional incisions in the area of traumatized tissue remains. We therefore recommend caution in the use of assisted fibular fixation.

03. Results

Intramedullary nailing fixation of tibial stem fractures can yield good results. Healing rates of intramedullary nailing of the tibia have been reported in different studies. With the use of modern implants and appropriate surgical techniques, healing rates are expected to exceed 90 %. The healing rate of tibial stem fractures that failed to heal after intramedullary nail fixation was dramatically improved after internal fixation with a second expanded intramedullary nail.

Outcome assessment at one year after surgery showed that up to 44 % of patients continued to have functional limitations in the injured lower extremity, and up to 47 % continued to report work-related disability at one year after surgery. The study suggests that patients treated with intramedullary nailing of the tibia continue to have significant functional limitations in the long term. Surgeons should be aware of these issues and advise patients accordingly!

四. Postoperative complications

01. Pre-patellar pain

Anterior patellofemoral pain is a common complication after intramedullary nail fixation of tibial stem fractures. Studies have shown that approximately 47 % of patients after intramedullary nailing may develop prepatellar pain, the etiology of which is not fully understood. Potential influencing factors may include traumatic and medical injury to intra-articular structures, injury to the infrapatellar branch of the saphenous nerve, weakness of the thigh muscles secondary to suppression of pain-related neuromuscular reflexes, fibrosis of the fat pad leading to impingement, reactive patellar tendonitis, bending strain from intramedullary nailing over the proximal portion of the tibia, and protrusion of the proximal end of the nail.

When studying the etiology of prepatellar pain after intramedullary nailing, the transpatellar tendon approach was compared with the parapatellar approach. The transpatellar tendon approach may be associated with a higher incidence of postoperative knee pain. However, prospective randomized clinical data did not show any significant difference between the transpatellar tendon approach and the parapatellar approach.

The efficacy of selective removal of internal fixation to address prepatellar pain after tibial intramedullary nailing is uncertain. We recommend that removal of the intramedullary tibial nail be considered if a mechanical etiology can be identified, such as nail protrusion or a protruding interlocking screw. However, the benefit of tibial intramedullary nail removal in symptomatic patients remains questionable.

Regarding postoperative prepatellar pain, the cause of the pain could not be clearly demonstrated in the initial clinical study of intramedullary nail fixation of the tibial nail on the patella in the semi-extended position. Therefore, large clinical studies with long-term follow-up are necessary to confirm the effect of intramedullary nail fixation in the suprapatellar approach on postoperative prepatellar pain.

02.Poor postoperative alignment

Post-traumatic osteoarthritis remains a significant problem after treatment of tibial stem fractures with intramedullary nailing. Biomechanical studies have shown that tibial malalignment may result in significant changes in contact pressures at the adjacent ankle and knee joints.

Clinical studies evaluating long-term clinical and imaging outcomes after tibial stem fracture have provided conflicting data on the sequelae of tibial malalignment, with no clear conclusions to date.

Reports of postoperative malalignment after intramedullary nailing of the tibia remain limited, with a small number of cases reported. Postoperative malrotation remains a common problem in tibial intramedullary nailing, and intraoperative assessment of tibial rotation remains challenging. To date, no clinical examination or imaging method has been established as the gold standard for intraoperative determination of tibial rotation.CT examination evaluation has shown that the rate of malrotation after intramedullary nailing of the tibia may be as high as 19 % to 41 %. In particular, external rotation deformities appear to be more common than internal rotation deformities. Clinical examination to assess postoperative malrotation was reported to be inaccurate and showed low correlation with CT assessment.

We believe that malalignment remains a long-term problem in tibial stem fractures treated with intramedullary nailing of the tibia. Despite conflicting data regarding the relationship between malalignment and clinical and imaging outcomes, we suggest that surgeons should strive to achieve anatomic alignment of fractures in order to control this variable and obtain optimal results.

五. Conclusion

Static locking expanded medullary intramedullary nailing remains the standard treatment for displaced tibial stem fractures. The correct entry point remains a critical part of the surgical procedure. The suprapatellar approach in the semi-extended position is considered a safe and effective procedure, and future studies need to further evaluate the risks and benefits of this procedure. The attending surgeon should be familiar with contemporary repositioning techniques. If anatomic fracture alignment cannot be achieved through a closed approach, incisional reduction techniques should be considered. Good healing rates of more than 90 % can be achieved with both expanded and non-expanded intramedullary nailing. Despite good healing rates, patients still have long-term functional limitations. In particular, prepatellar pain remains a common complaint after tibial intramedullary nailing. In addition, malrotation after internal tibial fixation remains a common problem.

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