Intraarticular anatomic risks of tibial nailing

Suprapatellar nailing of tibial fractures-Indications and technique

Intramedullary nailing is the standard procedure for surgical treatment of closed and Gustilo-Anderson Grade I-II° open fractures of the tibial shaft. The use of intramedullary nailing for the treatment of proximal metaphyseal tibia fractures is frequently followed by postoperative malalignment, whereas plate osteosynthesis is associated with higher rates of postoperative infection. Intramedullary nailing of tibial fractures is generally performed through an infrapatellar approach. The injured extremity must be positioned at a minimum of 90° of flexion in the knee joint to achieve optimal exposure of the correct entry point. The tension of the quadriceps tendon causes a typical apex anterior angulation of the proximal fragment. The suprapatellar approach improves reduction of the fracture and reduces the occurrence of malalignment during intramedullary nailing of extra-articular proximal tibial fractures. The knee is positioned in 20° of flexion to neutralise traction forces secondary to the quadriceps muscle, thus preventing an apex anterior angulation of the proximal fragment. An additional advantage of the technique is that it allows the surgeon to avoid or minimise further soft tissue damage because of the distance between the optimal incision point and the usual area of soft tissue damage.

Suprapatellar nailing of tibial fractures: surgical hints

Intramedullary nailing of the tibia with suprapatellar entry and semi-extended positioning makes it technically easier to nail the proximal and distal fractures. The purpose of this article was to describe a simple method for suprapatellar nailing (SPN). A step-by-step run through of the surgical technique is described, including positioning of the patient. There are as yet only a few clinical studies that illustrate the complications with this method, and there has been no increased frequency of intraarticular damage. Within the body of the manuscript, information is included about intraarticular damage and comments with references about anterior knee pain.

Safe surgical technique: intramedullary nail fixation of tibial shaft fractures

Statically locked, reamed intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point is a crucial part of the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Numerous reduction techiques are available to achieve an anatomic fracture alignment and the treating surgeon should be familiar with these maneuvers. Open reduction techniques should be considered if anatomic fracture alignment cannot be achieved by closed means. Favorable union rates above 90 % can be achieved by both reamed and unreamed intramedullary nailing. Despite favorable union rates, patients continue to have functional long-term impairments. In particular, anterior knee pain remains a common complaint following intramedullary tibial nailing. Malrotation remains a commonly reported complication after tibial nailing. The effect of postoperative tibial malalignment on the clinical and radiographic outcome requires further investigation.

Advances in Intramedullary Nailing: Suprapatellar Nailing of Tibial Shaft Fractures in the Semiextended Position

Reamed locked intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Supra-patellar tibial nailing in the semiextended position has been suggested as a safe and effective surgical technique that allows mitigating certain challenges of the standard subpatellar approach. Suprapatellar nailing seems to facilitate achieving and maintaining fracture reduction, particularly in proximal third tibia fractures. Preliminary investigations have suggested that this technique is associated with a low rate of complications, including a reduced incidence of postoperative anterior knee pain. Further clinical investigations are necessary to establish overall complication rates and long-term subjective outcomes.

Intramedullary Tibial Nailing Reduces the Attachment Area and Ultimate Load of the Anterior Medial Meniscal Root: A Potential Explanation for Anterior Knee Pain in Female Patients and Smaller Patients

BACKGROUND

Intramedullary (IM) nailing is the treatment of choice among orthopaedic surgeons for tibial shaft fractures. However, because of the close proximity of the nail's insertion site to the anterior medial (AM) meniscal root on the tibial plateau, there is increased risk of iatrogenic injury to the meniscal root during nailing.

PURPOSE

To quantify the area of the AM meniscal root footprint damaged by IM tibial reaming and determine its subsequent effects on the ultimate failure load in female versus male knees.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve matched pairs (6 male and 6 female pairs; average age, 50.2 years) of human cadaveric knees were randomly assigned to native and reamed groups. In the reamed group, knees were reamed within the "safe zone" according to current guidelines for IM tibial nail insertion (3 mm lateral to the center of the tibial tubercle and adjacent to the anterior margin of the tibial plateau). The attachment areas and ultimate failure load were quantified and compared with paired knees in the native group.

RESULTS

Intra-articular reaming within the "safe zone" for IM tibial nail insertion did not significantly decrease the AM root attachment area or ultimate failure load in male specimens, as only 2 of the 6 knees were damaged by reaming. In contrast, all 6 of the AM roots in the female knees were damaged by reaming, and on average, reaming decreased the female AM root attachment area by 19% and significantly decreased ultimate failure load by 37% (P = .028). There was a strong negative correlation (R(2) = 0.77) between reamed tunnel-AM root overlap area and medial-lateral width in female but not in male knees.

CONCLUSION

Standard reaming for an IM tibial nail induced significant damage to the AM meniscal root in smaller, female specimens, whereas larger, male specimens were not affected.

CLINICAL RELEVANCE

These findings may suggest that improvements in current guidelines and surgical techniques are warranted to prevent iatrogenic injury to the AM meniscal root during intramedullary reaming for tibial shaft fractures in females and in smaller patients.

[Suprapatellar approach to tibial medullary nailing with electromagnetic field-guided distal locking]

Closed tibial shaft fractures are the domain of intramedullary nailing. With the introduction of new nail designs and technologies, even small, dislocated distal fragments can be anatomically aligned and safely fixed. Unsolved or to a lesser degree controlled are the problems of distal locking in the freehand technique, which can still be difficult and can lead to a significant radiation exposure, and how to control very short proximal tibial fragments in metaphyseal tibial fractures or tibial segmental fractures, where the proximal fracture line also runs through the metaphysis.By using a suprapatellar approach, i.e. a skin incision proximal to the patella with an entry point into the tibial bone from within the knee at the same site as for a standard infrapatellar approach, and then nailing the tibia in a semi-extended position, i.e. the knee is only flexed 10-20°, the intraoperative dislocation of a short proximal fragment can be avoided. The main indications for semi-extended tibial nailing are a short diaphyseal fragment in an isolated tibial shaft fracture, a segmental fracture where the proximal fracture line is metaphyseal and in patients where infrapatellar soft tissues are compromised.The use of the electromagnetic guidance system SureShot® generates reliable and reproducible results, reduces the operating time and is independent from radiation for distal locking.

Anterior meniscus root avulsion following intramedullary nailing for a tibial shaft fracture

This paper presents the first reported case of iatrogenic injury to the anterior medial meniscal root attachment following intramedullary nailing for a tibial shaft fracture. The patient experienced a closed right tibia-fibula fracture 7 years prior to presentation, which was treated with a reamed intramedullary nail. The nail was removed 3 years after the index surgery due to chronic anterior knee pain, which persisted following hardware removal. At presentation, the patient was diagnosed with an anterior horn medial meniscal root tear likely secondary to insertion of the intramedullary nail through the anatomic footprint of the anterior medial root. After undergoing a medial meniscus anterior horn root repair, the patient was asymptomatic and resumed normal activities.

LEVEL OF EVIDENCE

Case report, Level IV.

Radiographic identification of the anterior and posterior root attachments of the medial and lateral menisci

BACKGROUND

Anatomic root placement is necessary to restore native meniscal function during meniscal root repair. Radiographic guidelines for anatomic root placement are essential to improve the accuracy and consistency of anatomic root repair and to optimize outcomes after surgery.

PURPOSE

To define quantitative radiographic guidelines for identification of the anterior and posterior root attachments of the medial and lateral menisci on anteroposterior (AP) and lateral radiographic views.

STUDY DESIGN

Descriptive laboratory study.

METHODS

The anterior and posterior roots of the medial and lateral menisci were identified in 12 human cadaveric specimens (average age, 51.3 years; age range, 39-65 years) and labeled using 2-mm radiopaque spheres. True AP and lateral radiographs were obtained, and 2 raters independently measured blinded radiographs in relation to pertinent landmarks and radiographic reference lines.

RESULTS

On AP radiographs, the anteromedial and posteromedial roots were, on average, 31.9 ± 5.0 mm and 36.3 ± 3.5 mm lateral to the edge of the medial tibial plateau, respectively. The anterolateral and posterolateral roots were, on average, 37.9 ± 5.2 mm and 39.3 ± 3.8 mm medial to the edge of the lateral tibial plateau, respectively. On lateral radiographs, the anteromedial and anterolateral roots were, on average, 4.8 ± 3.7 mm and 20.5 ± 4.3 mm posterior to the anterior margin of the tibial plateau, respectively. The posteromedial and posterolateral roots were, on average, 18.0 ± 2.8 mm and 19.8 ± 3.5 mm anterior to the posterior margin of the tibial plateau, respectively. The intrarater and interrater intraclass correlation coefficients (ICCs) were >0.958, demonstrating excellent reliability.

CONCLUSION

The meniscal root attachment sites were quantitatively and reproducibly defined with respect to anatomic landmarks and superimposed radiographic reference lines. The high ICCs indicate that the measured radiographic relationships are a consistent means for evaluating meniscal root positions.

CLINICAL RELEVANCE

This study demonstrated consistent and reproducible radiographic guidelines for the location of the meniscal roots. These measurements may be used to assess root positions on intraoperative fluoroscopy and postoperative radiographs.

Controversies in the intramedullary nailing of proximal and distal tibia fractures

Management of tibia fractures by internal fixation, particularly intramedullary nails, has become the standard for diaphyseal fractures. However, for metaphyseal fractures or those at the metaphyseal-diaphyseal junction, choice of fixation device and technique is controversial. For distal tibia fractures, nailing and plating techniques may be used, the primary goal of each being to achieve acceptable alignment with minimal complications. Different techniques for reduction of these fractures are available and can be applied with either fixation device. Overall outcomes appear to be nearly equivalent, with minor differences in complications. Proximal tibia fractures can be fixed using nailing, which is associated with deformity of the proximal short segment. A newer technique-suprapatellar nailing-may minimize these problems, and use of this method has been increasing in trauma centers. However, most of the data are still largely based on case series.

Semiextended intramedullary nailing of the tibia using a suprapatellar approach: radiographic results and clinical outcomes at a minimum of 12 months follow-up

OBJECTIVE

To evaluate the clinical and radiographic results associated with the use of a percutaneous suprapatellar (SP) portal and accompanying instrumentation for tibial intramedullary nail (IMN) insertion using a semiextended approach.

DESIGN

Prospective, nonrandomized, nonconsecutive study.

SETTING

Level 1 trauma center.

PATIENTS AND METHODS

From June 2007 to January 2011, 56 fractures (55 patients) underwent intramedullary nailing of a tibia fracture with a semiextended approach through a SP portal. Radiographic and clinical follow-up examinations were performed at a minimum of 1 year after the index procedure. Measurements included bone healing, tibial alignment, knee range of motion, pain drawings, pain scoring (visual analogue scale), functional outcome (Lysholm and SF-36 scoring), evaluation of prenail and postnail insertion arthroscopic images of the patella-femoral (PF) joint (subgroup of study patients), and 1-year follow-up magnetic resonance imaging (MRI) scans (STIR and T2 gradient echo) of the knee to evaluate the PF joint cartilage. MRI scans were reviewed by an independent bone radiologist, whereas arthroscopic images were evaluated by an independent sports medicine fellowship-trained orthopaedic surgeon.

RESULTS

Thirty-six patients (37 fractures) were available for follow-up at a minimum of 1 year (range: 12-49 months) after the index procedure. All but 2 fractures healed after the index procedure (94.6%). There was 1 radiographic malunion (2.7%). The mean Lysholm knee score was 82.14. Mean SF-36 physical and mental scores were 40.8 and 46.0, respectively. Mean arc of knee motion was 124.4 degrees for the affected extremity compared with 127.2 degrees for the contralateral knee. One patient (2.7%) complained of mild pain at the scar, but no patient complained of anterior knee pain either at the PF joint or at the anterior proximal tibia. In 13 of 15 patients undergoing an arthroscopic assessment of the PF joint, prenail and postnail insertion, no cartilage changes, or pressure points were seen either at the patella or at the trochlea groove. Two patients had grade II chondromalacia of the trochlea immediately after the procedure, but these did not correspond with either MRI scans or clinical findings at 1 year. When the remainder of the 1-year MRI scans were reviewed, 1 knee (2.7%) in a patient that did not have an arthroscopic examination was found to have grade II chondromalacia in the PF joint, but this did not correlate with the clinical examination, which was normal.

CONCLUSIONS

This is the first paper to critically document clinical and radiographic results using the percutaneous SP portal with the semiextended approach for IMN of the tibia. Our 1 year results indicate that the procedure resulted in excellent tibial alignment, union, and knee range of motion, with rare sequelae in the PF joint based on immediate arthroscopy and 1-year MRI scans and clinical examinations. Even more interesting was the absence of anterior tibial pain often found when a tibial nail is inserted in a standard fashion.

Techniques for the surgical treatment of distal tibia fractures

Surgical management of extra-articular distal tibia fractures has evolved because of the high rate of complications with conventional techniques and the technically challenging aspects of the surgery. Open reduction and internal fixation with plating or nailing remain the gold standards of treatment, and minimally invasive techniques have reduced wound complications and increased healing. Adequate reduction and stabilization as well as appropriate soft tissue management are imperative to achieving good outcomes in these fractures.

Semiextended intramedullary nailing of the tibia using a suprapatellar approach: radiographic results and clinical outcomes at a minimum of 12 months follow-up

OBJECTIVE

To evaluate the clinical and radiographic results associated with the use of a percutaneous suprapatellar (SP) portal and accompanying instrumentation for tibial intramedullary nail (IMN) insertion using a semiextended approach.

DESIGN

Prospective, nonrandomized, nonconsecutive study.

SETTING

Level 1 trauma center.

PATIENTS AND METHODS

From June 2007 to January 2011, 56 fractures (55 patients) underwent intramedullary nailing of a tibia fracture with a semiextended approach through a SP portal. Radiographic and clinical follow-up examinations were performed at a minimum of 1 year after the index procedure. Measurements included bone healing, tibial alignment, knee range of motion, pain drawings, pain scoring (visual analogue scale), functional outcome (Lysholm and SF-36 scoring), evaluation of prenail and postnail insertion arthroscopic images of the patella-femoral (PF) joint (subgroup of study patients), and 1-year follow-up magnetic resonance imaging (MRI) scans (STIR and T2 gradient echo) of the knee to evaluate the PF joint cartilage. MRI scans were reviewed by an independent bone radiologist, whereas arthroscopic images were evaluated by an independent sports medicine fellowship-trained orthopaedic surgeon.

RESULTS

Thirty-six patients (37 fractures) were available for follow-up at a minimum of 1 year (range: 12-49 months) after the index procedure. All but 2 fractures healed after the index procedure (94.6%). There was 1 radiographic malunion (2.7%). The mean Lysholm knee score was 82.14. Mean SF-36 physical and mental scores were 40.8 and 46.0, respectively. Mean arc of knee motion was 124.4 degrees for the affected extremity compared with 127.2 degrees for the contralateral knee. One patient (2.7%) complained of mild pain at the scar, but no patient complained of anterior knee pain either at the PF joint or at the anterior proximal tibia. In 13 of 15 patients undergoing an arthroscopic assessment of the PF joint, prenail and postnail insertion, no cartilage changes, or pressure points were seen either at the patella or at the trochlea groove. Two patients had grade II chondromalacia of the trochlea immediately after the procedure, but these did not correspond with either MRI scans or clinical findings at 1 year. When the remainder of the 1-year MRI scans were reviewed, 1 knee (2.7%) in a patient that did not have an arthroscopic examination was found to have grade II chondromalacia in the PF joint, but this did not correlate with the clinical examination, which was normal.

CONCLUSIONS

This is the first paper to critically document clinical and radiographic results using the percutaneous SP portal with the semiextended approach for IMN of the tibia. Our 1 year results indicate that the procedure resulted in excellent tibial alignment, union, and knee range of motion, with rare sequelae in the PF joint based on immediate arthroscopy and 1-year MRI scans and clinical examinations. Even more interesting was the absence of anterior tibial pain often found when a tibial nail is inserted in a standard fashion.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Radiologic outcome and patient-reported function after intramedullary nailing: a comparison of the retropatellar and infrapatellar approach

OBJECTIVES

The purpose of this study was to compare the patient-reported functional outcomes after intramedullary nailing of the tibia through a retropatellar or infrapatellar approach. Radiographic assessment of nail entry point and accuracy of fracture reduction were included to aid in the identification of variables that may explain any difference in patient-reported outcomes.

DESIGN

A retrospective radiographic and questionnaire-based assessment of patient-reported outcomes and complications after tibial nailing for trauma or limb reconstruction through a retropatellar or infrapatellar approach.

SETTING

Regional limb reconstruction unit within a university teaching hospital.

PATIENTS/PARTICIPANTS

Two consecutive series of 38 patients with intramedullary tibial nails inserted through a retropatellar approach, and 36 patients with a tibial nail inserted through an infrapatellar approach.

INTERVENTION

Tibial nail insertion through either a retropatellar or infrapatellar approach.

MAIN OUTCOME MEASURES

Patient-reported outcomes and complication rates and radiographic assessment of fracture reduction and nail insertion entry point.

RESULTS

No significant difference was seen in Kujala score as a measure of anterior knee pain (P = 0.217), either in the physical (P = 0.372) or mental (0.504) components of the SF-12 between the groups, although there was a trend toward symptomatic intrusive knee pain in the infrapatellar group. A more accurate fracture reduction, both in terms of angulation (P = 0.003) and translation (P = 0.010) in the coronal plane, was seen in the retropatellar group. The entry point for nail insertion was more accurate in both the sagittal (P = 0.011) and coronal (P = 0.014) planes.

CONCLUSIONS

Retropatellar tibial nail insertion is not associated with more anterior knee pain when compared with infrapatellar nail insertion but is associated with more accurate nail insertion and fracture reduction.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Techniques for intramedullary nailing of proximal tibia fractures

Despite poor early results with intramedullary nailing of extra-articular proximal tibia fractures, improvements in surgical technique and implant design modifications have resulted in more acceptable outcomes. However, prevention of the commonly encountered apex anterior and/or valgus deformities remains a challenge when treating these injuries. It is necessary for the surgeon to recognize this and know how to neutralize these forces. Surgeons should be comfortable using a variety of the reduction techniques presented to minimize fracture malalignment.

Influence of knee flexion and atraumatic mobilisation of infrapatellar fat pad on incidence and severity of anterior knee pain after tibial nailing

We evaluated the incidence and aetiology of anterior knee pain (AKP) in a series of patients that underwent intramedullary nailing for stabilisation of tibial fractures. During the preparation of the entry site no excision of the infrapatellar fat was allowed and electrical haemostasis was kept at the lowest level. Medullary canal was reamed and the nails inserted in position of knee flexion over 100 degrees. All fractures were fixed using medial paratendinous approach. Functional outcome was measured using Lysholm knee score. The knee range of movement and return to previous level of activity were also documented and analysed. Mean follow up was 38.9 months (range 12-84 months). In total 60 patients with 62 tibial shaft fractures were analysed. The mean age at the time of final follow up was 49.4 years (range 20-87). In 22 (35.5%) a newly developed and persisting pain in the anterior region of the operated knee was reported. According to VAP scale, the pain was mild (VAS 1-3) in 12 cases (19.4%) and moderate (VAS 4-6) in 10 (16.1%). In 16 cases (73%) the pain was noticed 6-12 months after injury and subjectively related to return to full range of working and recreational activities. The mean Lysholm knee score in the group without AKP was 90.8. In the AKP group with mild pain it was 88.4 and in the group with moderate AKP it was 79.9. Complete return to previous professional and recreational activities occurred in 49/60 patients (81.7%). Content with the treatment regarding expectations in recovery dynamics and return to desired level of activity was present in 98.3% of patients; one patient was unsatisfied with the treatment. Our results indicate that respecting the physiological motion of Hoffa pad and menisci during knee flexion, accompanied with atraumatic mobilisation of retrotendinous fat, reduces incidence and severity of anterior knee pain following intramedullary fixation of tibial shaft fractures.

Comparison of insertional trauma between suprapatellar and infrapatellar portals for tibial nailing

The purpose of this study was to determine differences in insertional articular trauma in infrapatellar tibial portal and suprapatellar portal intramedullary tibial nail insertion techniques. A cadaveric study was performed on 10 matched pairs of fresh-frozen adult cadaver lower extremities with intact extensor mechanisms. Two study groups with 10 limbs each were created: left lower limbs were treated with a standard medial parapatellar nailing portal and right lower limbs were treated with a suprapatellar tibial nailing portal. Start points were created under fluoroscopic guidance in anteroposterior and mediolateral planes. A start wire was placed and opening reaming was performed on the specimens using instrumentation specific to the nailing portal. Specimens were then dissected by medial parapatellar arthrotomy, revealing the intra-articular condition of the knee structures. The border of the tibial entry reamer hole was measured to the anterior horns of the menisci, anterior cruciate ligament root, and intermeniscal ligament using a digital caliper accurate to 0.02 mm. The structure was considered damaged if the structure was obviously damaged on visual inspection or if a measurement was less than 1 mm. Impact to intra-articular structures was numerically lower in the suprapatellar group (2/10) compared with the infrapatellar group (4/10), but the difference was not statistically significant between the 2 groups (P=.629). The suprapatellar portal approach to the tibial start point demonstrated a lower overall incidence of damage to intra-articular structures, but no significant statistical difference existed between the 2 treatment groups.

Quantification of anterior cortical bone removal and intermeniscal ligament damage at the tibial nail entry zone using parapatellar and retropatellar approaches

OBJECTIVES

Anterior cortical bone removal at the tibial nail entry zone has been shown to alter biomechanical properties of the proximal tibia. However, no study has quantified the amount of bone removed. The purpose of this study was to quantify the amount of anterior bone removed at the nail entry zone and assess damage to adjacent intra-articular structures using both parapatellar and retropatellar techniques.

METHODS

The study was performed using 36 cadaveric knees (18 medial parapatellar and 18 retropatellar approaches). A guide pin was placed in the anatomic safe zone using fluoroscopic guidance and a 12.5-mm entry reamer used to open medullary canal. Soft tissues were removed, damage to intra-articular structures recorded, and size of osseous defect created in proximal tibia measured.

RESULTS

The surface area of bone removed with portal creation was not significantly larger with retropatellar (228.4 ± 38.1 mm) versus parapatellar technique (207.9 ± 33.4 mm(2); P = 0.108). This was substantially different than if the entry hole was perfectly round (122.7 mm(2)). No knee went without some damage to intra-articular structures using the parapatellar technique, as opposed to 33% knees with retropatellar technique (P = 0.019). Intermeniscal (IM) ligament was damaged in 83% parapatellar and 56% retropatellar knees (P = 0.146).

CONCLUSIONS

A substantial amount of anterior bone is removed during nail entry portal creation using both parapatellar and retropatellar techniques. Intra-articular structure damage, most commonly IM ligament disruption, was also found to occur at a lower rate with retropatellar technique. Avoidance of both anterior bone removal and IM ligament damage may not be possible because of size and geometrical constraints.

Two-stage procedure in anterior cruciate ligament revision surgery: a five-year follow-up prospective study

PURPOSE

The purpose of this study was to show that this two-stage procedure for ACL (anterior cruciate ligament) revision surgery could be straight-forward and provide satisfactory clinical and functional outcomes.

MATERIALS

This is a five-year prospective analysis of clinical and functional data on 30 patients (19 men and 11 women; average age 29.1 ± 5.4) who underwent a two-stage ACL revision procedure after traumatic re-rupture of the ACL. Diagnosis was on Lachman and pivot-shift tests, arthrometer 30-lb KT-1000 side-to-side findings, and on MRI and arthroscopic assessments.

RESULTS

Postoperative IKDC and Lysholm scores were significantly improved compared to baseline values (P < 0.001). At the last follow up, 20 of 30 patients (66.7%) had returned to preoperative sport activity level (nine elite athletes, 11 county level), seven had changed to lower sport levels, and three had given up any sport activity. At the same appointment, 11 patients had degenerative changes. All these patients reported significantly lower Lysholm scores compared to patients without any degenerative change (p < 0.001).

CONCLUSIONS

In ACL revision surgery, when the first femoral tunnel has been correctly placed, this procedure allows safe filling of large bony defects, with no donor site comorbidities. It provides comfortable clinical, functional and imaging outcomes.

Biomechanical effects of the nail entry zone and anterior cortical bone loss on the proximal tibia

OBJECTIVES

The aims of this study were as follows: to determine if the presence of the nail entry zone alters the biomechanics of the proximal tibia after intramedullary (IM) nailing using a computational model; to determine if nail removal restores normal biomechanics to the proximal tibia; and to determine if these effects are magnified with anterior cortical bone loss.

METHODS

Three-dimensional finite element (FE) tibial models were developed and used for this study: an intact tibia, a nailed tibia, and a tibia with the nail removed. One matched pair of fresh-frozen cadaver tibias was obtained to construct and validate the FE model. The tibias underwent computed tomography scanning, and geometric models were obtained from computed tomography data through volumetric reconstruction. The left tibia was implanted with an unlocked IM nail. The experimental validation of the models was performed by comparing experimental and FE data. Anterior cortical bone of the proximal tibia was removed down to the tibial tubercle on the models to simulate a worst-case scenario of its removal during an IM nailing procedure. Three load cases were considered for each FE tibial model: standing, walking, and single-limb kneeling.

RESULTS

The principal strain values of the proximal tibia with the nail entry zone were increased in comparison to the intact tibia in all 3 loading scenarios (+350%-550%). These effects were greatly magnified with anterior cortical bone loss near the nail entry zone (6-fold increase). The presence of the nail increased the principal strain values in the proximal tibia both with an intact and a disrupted anterior cortex in all loading scenarios, and these values remain elevated even with removal of the nail. The values predicted by the FE model were in good agreement with the experimentally measured strains (R = 0.92).

CONCLUSION

The nail entry zone in the proximal tibia greatly increases the principle strain values when standing, walking, and kneeling. The presence of the nail results in the highest strain values, but they do not return to normal when the nail is removed. These effects are significantly amplified with removal of the anterior tibial cortex near the nail entry zone.

Problems, tricks, and pearls in intramedullary nailing of proximal third tibial fractures

Proximal third tibial shaft fractures have been notoriously difficult to treat. Early reports resulting in high rates of malunion and fixation failure trended surgeons to move away from intramedullary nailing as definitive treatment. However, with the advent of a deepened understanding of the surround anatomy, several techniques have been developed to help maintain proper alignment without early failure or malunion. This review provides a concise update on the tips, tricks, and pearls available in achieving a stable well-aligned construct when definitively treating proximal third tibial shaft fractures via intramedullary nail.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Knee pain correlates with union after tibial nailing

OBJECTIVES

The purpose of this study is to evaluate the change in quantitatively scored knee pain during union.

DESIGN

This is a retrospective review of prospectively collected data over a 15-year period.

SETTING

Academic medical center.

PATIENTS

All patients treated with an intramedullary nail were evaluated for knee pain and union. Four hundred twenty-eight patients with 443 tibia fractures were included.

INTERVENTION

All tibia fractures were treated with an intramedullary nail.

OUTCOMES

Patient-based knee pain was scored from 0 to 3. Fracture union was also graded using a modified Hammer score based on cortical bridging and remodeling.

RESULTS

We found a significant inverse association between pain and union score (P < 0.01). In contradistinction, there was not a correlation between time from surgery and pain (P = 0.13). Because union score and time were related, a model was created with both parameters. This model demonstrated a statistical correlation with union score (P < 0.01), but not for time from surgery (P = 0.18).

CONCLUSIONS

We postulated that knee pain may correlate with either union or time from surgery. We found a statistically significant, negative correlation between knee pain and fracture union. There was no such association between pain and time from surgery.

Intramedullary nailing of extra-articular proximal tibia fractures

Tibial fractures are the most common long bone fractures. Extra-articular proximal tibia fractures account for approximately 5% to 11% of all tibial shaft fractures. The benefits of intramedullary nailing of these fractures include load sharing, sparing of the extraosseous blood supply, and avoidance of additional soft-tissue dissection, thereby minimizing the risk of postoperative complications. A significant rate of malalignment has been reported with intramedullary nailing of proximal tibia fractures, however. Malalignment typically presents as apex anterior and valgus angulation. Several nailing methods and reduction techniques have been developed to minimize this complication, including the use of a proper starting point and insertion angle, blocking screws, unicortical plates, a universal distractor, and alternative positioning and approaches. Use of one or more of these techniques has resulted in a reported average malreduction rate of 8.2%.

Extra-articular technique for semiextended tibial nailing

Intramedullary nailing is a widely accepted technique for the stabilization of unstable diaphyseal tibia fractures. When this method of stabilization is applied to proximal and distal metadiaphyseal fractures, achieving and maintaining fracture reduction is more difficult. The intramedullary nailing of proximal metadiaphyseal fractures in semiextension has been advocated to make stabilization less difficult. The intra-articular nature of this technique makes it less appealing. We present a nailing technique that facilitates extra-articular semiextended tibial nailing. The technique simplifies intraoperative imaging, fracture reduction, and maintenance of reduction during nail insertion and locking.

Retropatellar technique for intramedullary nailing of proximal tibia fractures: a cadaveric assessment

OBJECTIVE

To investigate if the radiographically correct and anatomically safe starting point and the appropriate sagittal plane vector could be obtained using a retropatellar technique for proximal tibia fractures treated with an intramedullary device.

METHODS

We performed a cadaveric and radiographic study utilizing 16 limbs. We performed a retropatellar approach via longitudinal quadriceps split, passed a specialized trocar through the patellofemoral joint and onto the superior aspect of the tibia, and inserted Kirschner wires into the anatomic safe zone of the tibial plateau at 0, 10, 20, 30, 40, and 50 degrees of knee flexion utilizing biplanar fluoroscopy. We recorded knee flexion with a goniometer and the entrance vector of the Kirschner wire in relation to the anterior tibial cortex.

SETTING

University-affiliated cadaver and anatomy laboratory.

RESULTS

There was a progressive increase in the ability to obtain the correct anatomical start site from 1 of 16 (6.25%) at full extension to 12 of 16 (75%) at 50 degrees of knee flexion (P = 0.00098). A statistically significant decrease in the average sagittal plane entrance vector in relation to the anterior tibial cortex was found from 23.1 degrees at full extension to -0.41 degrees at 50 degrees of knee flexion (P < 0.0001).

CONCLUSIONS

The retropatellar technique allows the radiographically defined correct start site to be localized, particularly at higher degrees of knee flexion. More favorable intramedullary nail insertion angles were possible with the retropatellar technique, particularly with knee flexion angles greater than 20 degrees. The retropatellar technique demands further investigations to further delineate its advantages, limitations, and possible risks to local anatomy.

The retropatellar portal as an alternative site for tibial nail insertion: a cadaveric study

OBJECTIVE

To define spatial relationships between major intra-articular structures of the knee and the entry site of a tibial nail inserted using a retropatellar portal.

DESIGN

Cadaveric study using 16 fresh-frozen limbs.

SETTING

University-affiliated cadaver and anatomy laboratory.

RESULTS

The mean distance of the nail entry site and the medial and lateral menisci were 6.6 ± 3.2 mm and 6.4 ± 4.4 mm, respectively. The distance to the medial and lateral articular surfaces were 5.6 ± 3.6 mm and 7.4 ± 4.2 mm, respectively. The mean distance to the anterior cruciate ligament footprint was 7.5 ± 3.5 mm. The lateral meniscus was never injured during the procedure. The anterior cruciate ligament was undisturbed in all specimens. The medial meniscus was injured 1 to 2 mm in 12.5% of specimens. The intermeniscal ligament was injured 1 to 2 mm in 81.2% of the specimens.

CONCLUSION

The intermeniscal ligament and medial meniscus are at the most risk during intramedullary nailing of the tibia using the retropatellar technique. This may be corrected by avoiding an excessively medial start point. Damage to the intermeniscal ligament and medial meniscus occurs more commonly with the retropatellar portal, but this damage was never more than 1 to 2 mm. This risk, however, appears similar to the pattern and incidence of injury that occurred in prior studies investigating tibial nail insertion through a standard patellar tendon approach. The retropatellar technique demands clinical investigation to further define both its safety and its use.

LOCALIZATION OF THE TIBIAL ENTRY POINT

Objective: To assess the intramedullary nail entry point in the proximal region of the tibia, through a questionnaire. Methods: 230 participants undergoing treatment for tibial fractures were interviewed. The questionnaire was created with three sections that could be answered in a ”Yes” or “No” format and a fourth section that had two figures representing anteroposterior (AP) and lateral view x-rays that could be answered in an “A, “B” or “C” format. Results: The most frequent reason was “ease of access” (67.8%), followed by “better nail insertion access” (60.9%) and, in third place, “to prevent knee pain” (27.4%). The reasons for choosing the access so as to “prevent knee pain” and “avoid tendinitis” had a significant relationship with points “A” and “C” of the schematic AP x-ray figure, especially “C” (medial tibial crest). There were no significant differences between the types of access to the patellar ligament in the schematic AP and lateral x-ray figures between age groups. Conclusion: The greater the age was, the larger the proportion choosing the question “to avoid valgus deformity” was. The reasons from a medical (practical) perspective related to the type of access in the transpatellar ligament, while the reasons from a patient (functional) perspective related to medial parapatellar access. Transpatellar access was chosen by most of the participants (66.5%).

Three-dimensional analysis of the intramedullary canal axis of tibia: clinical relevance to tibia intramedullary nailing

INTRODUCTION

The aim of this study was to evaluate the appropriate insertion point for a tibial intramedullary nail by measuring the intramedullary canal axis of the tibia in three dimensions.

METHODS

Forty-three pairs (14 males and 29 females) of cadaveric low extremities (mean age 51 years, range 21-60 years) were analyzed to evaluate the appropriate insertion point for a tibial intramedullary nail by measuring the intramedullary canal axis of the tibia in three dimensions. Computed tomography was performed on 86 lower extremities from the hip to the ankle on cadavers. The location of the intramedullary canal axis of the tibia passing through the tibial plateau, the canal axis center (CAC), was measured. The correlations between the lateral tibial spine (LTS) and the mediolateral coordinates of the CAC were analyzed.

RESULTS

The CAC was located at 56.5% distance from the medial cortex. On average, the CAC was located 1.1 mm medial from the LTS. The mean length from the surface center to the CAC was lateral 4.5 mm.

CONCLUSION

The appropriate insertion point for a tibial nail was the slightly medial aspect of the LTS. However, it led to the point with a broad range, increasing the necessity to take individual variations into consideration.

Influence of medial parapatellar nail insertion on alignment in proximal tibia fractures--special consideration of the fracture level

INTRODUCTION

Although a lateral starting point for tibial nailing is recommended to avoid valgus misalignment, higher rates of intra-articular damage were described compared with a medial parapatellar approach. The aim of this anatomic study was to evaluate the fracture level allowing for a safe medial nail entry point without misalignment or dislocation of fragments.

MATERIALS AND METHODS

Thirty-two fresh-frozen cadaver lower extremities were used to create 1-cm osteotomies at four different levels (n = 8) from 2 cm to 8 cm below the tibial tuberosity. Nine-millimeter unreamed solid titanium tibial nails (Connex, I.T.S. Spectromed, Lassnitzhohe, Austria) were inserted from a medial parapatellar incision. Misalignment (degree) and dislocation of the distal fragment were measured in the frontal and sagittal plane.

RESULTS

A medial parapatellar approach for tibial nail insertion mainly caused valgus and anterior bow misalignment and ventral and medial fragment displacement. Mean misalignment and fragment displacement did not exceed 0.5 degree if the osteotomy was performed 8 cm to 9 cm below the tibial tuberosity.

DISCUSSION

According to the results of this study, a medial parapatellar approach can be performed without misalignment and fragment dislocation in proximal tibia fractures extending 8 cm or more below the tibial tuberosity.

Knee medial compartment contact pressure increases with release of the type I anterior intermeniscal ligament

BACKGROUND

The anterior intermeniscal ligament of the knee is at risk during knee arthroscopy, anterior cruciate ligament reconstruction, and tibial nail insertion.

HYPOTHESIS

Release of the anterior intermeniscal ligament, in knees with type I ligaments, will result in altered contact pressures in the medial compartment.

STUDY DESIGN

Controlled laboratory study.

METHODS

Five fresh-frozen human cadaveric knees with intact type I anterior intermeniscal ligaments were chosen for testing in a modified MTS machine from 0 degrees to 60 degrees of flexion under 2 conditions: (1) intact and (2) after sharp sectioning of the anterior intermeniscal ligament. Measurements were made using inframeniscal contact pressure sensors covering the medial compartment. Poststudy analysis was done in 10 degrees increments between 0 degrees and 60 degrees of flexion, looking at peak contact pressure and the amount of contact area seeing pressure.

RESULTS

Sectioning of the anterior intermeniscal ligament caused a statistically significant increase in the peak pressure at 20 degrees , 30 degrees , 40 degrees , and 50 degrees of knee flexion. The largest change occurred at 40 degrees of knee flexion, when the peak pressure increased by 27.5% (3.68 MPa to 4.69 MPa). Contact area decreased, although this difference was not statistically significant.

CONCLUSION

Release of the anterior intermeniscal ligament results in increased peak contact pressures in the medial compartment of the knee.

CLINICAL RELEVANCE

Care should be taken to avoid sacrifice of this ligament during surgery.

Anterior knee pain following the lateral parapatellar approach for tibial nailing

BACKGROUND

Anterior knee pain after intramedullary nailing of tibial shaft fractures is a common clinical problem, with various etiologies. We have used a lateral parapatellar approach with atraumatic elevation of the infrapatellar fat pad to expose the starting point. Our hypothesis was that this approach leads to a low incidence of knee pain.

METHODS

We conducted a retrospective study of 78 patients suffering from tibia fractures treated by a single surgeon. Fifty patients were available for the study. All fractures were fixed with a reamed intramedullary nail using the modified lateral approach. Complaints of knee pain and range of motion as well as keeling ability were examined in the clinic visit and recorded in the patients' charts. Lysholm knee scores were collected following the last follow-up visit. Average follow-up was 13 months (range 6-26 months).

RESULTS

Nine patients (19%) had subjective anterior knee pain when directly questioned. Eighty-two percentage of patients had no difficulty kneeling and this was significantly correlated with lack of knee pain. Good or excellent knee scores were reported by 92% of patients. Average knee flexion was 130 degrees . There was a negative correlation between the presence of open fracture and outcome. No correlation was found between knee pain and nail insertion depth or coronal alignment.

CONCLUSION

The modified lateral parapatellar approach with careful dissection of the fat pad may significantly reduce anterior knee pain after intramedullary nailing of the tibial shaft.

Operative treatment of ipsilateral noncontiguous unicondylar tibial plateau and shaft fractures: combining plates and nails

Unicondylar plateau fractures with ipsilateral noncontiguous tibial shaft fractures are rare injuries; over a 10-year period, we identified only 50 of these combined injuries in our series of 1586 tibial fractures. Modern locking plates and percutaneous techniques have been increasingly indicated for this injury pattern though this technique can compromise optimal fixation of the plateau and/or shaft fractures. For a number of years, we have combined intramedullary nails and plates for the treatment of these fractures with excellent results. With careful attention to some technical points, ipsilateral tibial plateau and shaft fractures can be managed successfully by combining 2 familiar techniques commonly employed for each injury in isolation.

Open diaphyseal long bone fractures: a reduction method using devitalized or extruded osseous fragments

Open diaphyseal and meta-diaphyseal fractures of the lower extremity remain therapeutically challenging. Currently accepted treatment methods consist of a thorough irrigation and debridement of nonviable tissue combined with locked intramedullary nailing. Although exact reduction parameters remain controversial, achievement of a satisfactory reduction becomes increasingly difficult with fracture comminution and overt bone loss. We describe the simple technique of using multiple associated devitalized tibial bone fragments to obtain an accurate reduction prior to intramedullary nailing. This technique can be extended to other long bone fractures.

A new harvest site for bone graft in anterior cruciate ligament revision surgery

During revision anterior cruciate ligament (ACL) surgery, femoral interference screws frequently require removal. This may lead to significant tunnel widening and possible graft fixation failure as a result. Solutions include drilling the revision tunnel in a different location, using stacked interference screws, or using bone graft to fill the defect. Autogenous iliac crest graft and allograft are both used, but there are significant comorbidities associated with each. We developed a new technique for harvesting autogenous bone graft that avoids many of the complications associated with other graft sources. By use of the existing surgical incision from the initial harvest of the bone-patellar tendon-bone autograft, bone from the medial tibial metaphyseal safe zone is harvested via an OATS tube harvester (Arthrex, Naples, FL). A bone plug 1 mm larger in size than the femoral defect is harvested and arthroscopically inserted via a press-fit technique. At 3 months after bone grafting, patients undergo revision ACL reconstruction. The proximal tibial metaphysis is a safe bone graft harvest site in revision ACL surgery and offers an effective method for filling large bony defects, allowing anatomic reconstruction of the ACL after bone healing has occurred. Furthermore, it eliminates the problems associated with allograft or use of a remote graft donor site.

Knee pain after tibial nailing: the role of nail prominence

We analyzed the relationship between knee pain after tibial nailing and nail prominence. We identified 70 patients in our trauma registry with healed fractures initially treated with intramedullary nails. Subjective pain and function were measured with visual analog pain scales and Lysholm knee scores at a mean of 20 months after fracture. These scores were compared with nail prominence measured on postoperative radiographs. More than 49% of patients had knee pain. Subjective knee pain was more common in women and patients with a smaller plateau width. Anterior nail prominence was associated with increased pain at rest. Patients with superior nail prominence had increased pain with kneeling and walking. Nail prominence correlated with increased knee pain. We think surgeons can decrease, but not eliminate, the severity of knee pain after tibial nailing by burying the tip of the nail as reflected on lateral radiographs.

LEVEL OF EVIDENCE

Prognostic Study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Surgical treatment of nonarticular distal tibia fractures

Distal tibia metaphyseal fractures can be difficult to manage. Treatment selection is influenced by the proximity of the fracture to the plafond, fracture displacement, comminution, and injury to the soft-tissue envelope. Nonsurgical management is possible for stable fractures with minimal shortening. Indications for intramedullary nailing have expanded to include distal metaphyseal tibia fractures. Intramedullary nailing allows atraumatic, closed stabilization while preserving the vascularity of the fracture site and integrity of the soft-tissue envelope. Intramedullary canal anatomy at this level prevents intimate contact between the nail and endosteum, however, and concerns have been raised regarding the biomechanical stability of fixation and risk of malunion. Plate fixation is effective in stabilizing distal tibia fractures. Conventional techniques involve extensive dissection and periosteal stripping, which increase the risk of soft-tissue complications. Percutaneous plating techniques use indirect reduction methods and allow stabilization of distal tibia fractures while preserving vascularity of the soft-tissue envelope. External fixation is effective in the setting of contaminated wounds or extensive soft-tissue injury. Careful preoperative planning with consideration for fracture pattern and soft-tissue condition helps guide implant selection and minimize postoperative complications.

Anterior knee pain and thigh muscle strength after intramedullary nailing of tibial shaft fractures: a report of 40 consecutive cases

OBJECTIVES

Chronic anterior knee pain is a common complication following intramedullary nailing of a tibial shaft fracture. The source of pain is often not known nor is the reason for a simultaneous decrease in thigh muscle strength. Anterior knee pain has also been reported following an anterior cruciate ligament rupture. No previous investigation has assessed whether weakness of the thigh muscles is associated with anterior knee pain following intramedullary nailing of tibial shaft fractures.

DESIGN

Prospective study.

SETTING

University Hospital of Tampere, University of Tampere.

PATIENTS

Fifty consecutive patients with a nailed tibial shaft fracture were initially included in the study. Ten patients did not have isokinetic strength testing for various reasons and were eliminated from the study.

MAIN OUTCOME MEASUREMENTS

Isokinetic muscle strength measurements were done in 40 patients at an average 3.2 +/- 0.4 (SD) years after nail insertion (1.7 +/- 0.3 years after the nail extraction).

RESULTS

Twelve (30%) patients were painless and 28 (70%) patients had anterior knee pain at follow-up. With reference to the hamstrings muscles, the mean peak torque deficit of the injured limb (as compared with the uninjured limb) was 2 +/- 11% in the painless group and 11 +/- 17% in the pain group at a speed of 60 degrees /s (P = 0.09, [95% CI for the group difference = -18% to 0%]). At a speed of 180 degrees /s, the corresponding deficits were -3 +/- 13% and 10 +/- 21% (P = 0.03, [95% CI for the group difference = -4% to -2%]). With reference to the quadriceps muscles, the mean peak torque deficit of the injured limb was 14 +/- 15% in the painless group and 15 +/- 15% in the pain group at speed of 60 degrees /s (P = 0.71, [95% CI for the group difference = -11% to 10%]). At a speed of 180 degrees /s, the corresponding deficits were 9 +/- 11% and 14 +/- 17% (P = 0.46, [95% CI for the group difference = -14% to 5%]).

CONCLUSION

Based on this prospective study, we conclude that anterior knee pain after intramedullary nailing of a tibial shaft fracture, although of multifactorial origin, may be related to deficiency in the flexion strength of the thigh muscles.

Incision placement for intramedullary tibial nailing: an anatomic study

OBJECTIVES

For intramedullary nailing of tibial shaft fractures, a recent study has determined that the entry site should be just medial to the lateral tibial spine at the anterior margin of the articular surface. Gaining access to this site is often through a medial parapatellar or transpatellar approach. Several studies have indicated that a transpatellar approach may contribute to anterior knee pain. Our study sought to use anatomic measurement to determine the ideal incision site for insertion of an intramedullary tibial nail. DESIGN Part I: survey of Orthopaedic Trauma Association (OTA) members. Part II: anatomic study.

SETTING

A Level I trauma center in Sacramento, California.

PARTICIPANTS

Part I: OTA members. Part II: a group of 56 healthy volunteers.

INTERVENTION

Part I: questionnaire sent to OTA members. Part II: clinical examination and radiographic analysis.

MAIN OUTCOME MEASUREMENTS

Part I: responses to questionnaire. Part II: anatomic measurements.

RESULTS

Part I: based on a questionnaire, OTA members use at least one or more approaches to access their preferred tibial nail entry site. Fifty-seven percent use only one type of approach in all cases. Part II: the authors performed a clinical and radiographic study in 56 volunteers (112 knees) to determine the relationship of the lateral tibial spine to the patellar tendon. On the basis of this information, the tendon was divided into thirds to account for the three most common surgical approaches. The entry site was in the lateral zone in 29 knees, the middle zone in 75 knees, and the medial zone in 8 knees. If divided equally into purely a medial or lateral zone to avoid a transpatellar approach, the starting point fell into the medial zone in 42 knees and the lateral zone in 70 knees.

CONCLUSIONS

Individual variations in patellar tendon anatomy should be considered when choosing the proper entry site for tibial nailing. Based on the assumption that the ideal entry point for tibial nailing is just medial to the tibial spine at the anterior margin of the articular surface, a preoperative fluoroscopic measurement before incision can guide the surgeon as to whether a medial parapatellar, transpatellar, or lateral parapatellar approach provides the most direct access to this entry site. The routine use of a single approach for all tibial nails may no longer be justified.

Current practice in the intramedullary nailing of tibial shaft fractures: an international survey

BACKGROUND

Tibial fractures are the most common of all long bone fractures. Although many tibial fractures may be managed conservatively, a certain subset, including unstable fractures and open fractures, require operative stabilization. Intramedullary nails have become the popular choice of implant in the treatment of tibial shaft fractures. The variability in outcomes with tibial shaft fractures may reflect technical aspects of the surgical procedure and perioperative care regimens among surgeons. Identifying the distribution of surgeons' preferences in nailing technique, and the rationale for their choices, will aid in focusing educational activities for the orthopedic community and planning future clinical trials. Our objectives were to clarify surgeons' opinions regarding technical aspects of surgery and perioperative care after intramedullary nailing of closed and open tibial shaft fractures, and to identify predictors of surgeons' preferences in technique and perioperative care.

METHODS

This study was a cross-sectional survey using focus groups, key informants, and sampling to redundancy strategies to develop a survey to examine surgeons' preferences in the treatment of tibial shaft fractures. The survey was pilot tested for clarity and content validity. We mailed this survey in July 2000 to 577 orthopedic surgeons who have an interest in trauma care. These were members of the Orthopaedic Trauma Association, American Academy of Orthopaedic Surgeons, or European AO International affiliated trauma centers. We used several strategies to improve response rates including personalized cover letters, stamped return envelopes, follow-up telephone calls, and repeat mailing of questionnaires. Main outcome measures included technical issues such as reduction, exposure, intramedullary reaming, and interlocking screws; and factors associated with surgeons' preferences such as age, fellowship, academic practice, and geographic location.

RESULTS

Four hundred forty-four surgeons (77%) responded. Sixty percent of respondents had an academic practice, 84% supervised residents, and 65.1% had fellowship training in trauma. Approximately half (51.5%) of surgeons used a tourniquet. The odds that a surgeon in Asia or Africa used tourniquets was 10 times that of a North American surgeon (p = 0.004 and p = 0.002, respectively). Patellar tendon retraction and an inferior-based entry portal was the popular choice among surgeons (70.1% and 70.8%, respectively). Surgeons from Australia (odds ratio [OR] = 50, p < 0.001), South America (OR = 9.0, p < 0.001), Europe (OR = 3.7, p = 0.001), and Asia (OR = 3.8, p = 0.006) were significantly more likely to use a patellar splitting approach compared with North American surgeons. In the perioperative care of open tibial shaft fractures, there was consensus in the use of intravenous antibiotics and wound irrigation (96.5% and 95.6%, respectively). However, we found considerable variability in surgeons' preference in wound irrigation pressures (high, 38.7%; low, 45.4%). Surgeons in South America were 10 times more likely to use low-pressure irrigation than North American surgeons (p = 0.0005). In grade IIIB open tibial shaft fractures, 94% of surgeons believed wound closure should be obtained within the first 7 days after the injury. A surgeon's geographic location was a significant predictor of the timing of soft tissue coverage (p = 0.001).

CONCLUSION

Consensus in the use of irrigation and intravenous antibiotics in open fractures was achieved among surgeons. However, there remains considerable variability in the surgical technique of intramedullary nailing, the duration of antibiotic use, and the timing of wound closure in open tibial fracture care. Continued education and large multicenter trials are needed to establish best practice in the operative treatment of tibial shaft fracture.

Tibial portal placement: the radiographic correlate of the anatomic safe zone

OBJECTIVE

To identify the radiographic correlate of the anatomic safe zone for tibial portal placement.

DESIGN

Cadaveric, anatomic, and radiographic study using twenty cadaveric knees. Kirschner wires were placed in the anatomic safe zone. Anteroposterior and lateral radiographs were taken to evaluate the portal placement.

SETTING

Anatomy laboratory.

OUTCOME MEASUREMENTS

Radiographic measurements of Kirschner wires placed in the anatomic safe zone.

RESULTS

The safe zone for tibial nail placement as seen on radiographs is just medial to the lateral tibial spine on the anteroposterior radiograph and immediately adjacent and anterior to the articular surface as visualized on the lateral radiograph. There is some variance on the anteroposterior radiograph but no variance on the lateral radiograph.

CONCLUSIONS

The placement of tibial nails in the superior portion of the tibia in the documented position generates the least risk to the intraarticular structures of the knee.