This document discusses the challenges of intramedullary (IM) nailing of proximal tibia fractures. It notes a reported malalignment rate of 44-84% with IM implants. Key points include recognizing troublesome fracture patterns, the importance of preoperative planning and imaging, starting point selection, and use of adjunctive techniques like clamps, blocking wires/screws, and unicortical plates to help maintain reduction during nailing. Proper application of reduction principles can help reduce risk of angular deformities, the most common complication.

1. PEARLS AND PITFALLS WITH
IM NAILING OF PROXIMAL
TIBIA FRACTURES
D R . B I P U L B O R T H A K U R
P R O F E S S O R & H O D ,
D E P T O F O R T H O P A E D I C S , S M C H

2. LEARNING OBJECTIVE
• Challenges in IM fixation of the
proximal tibia fracture
• Pitfalls of proximal tibia fracture
nailing
• Preoperative planning
– Recognizing troublesome injury
patterns
– Understanding the design of
newer implants
– Imaging
• Adjunctive techniques to
decrease the malalignment
– Proper entry point:
semiextended position;
suprapatellar and infrapatellar
approach
– Clamps
– Blocking wires and screws
– Universal distractor
– Unicortical plates

3. • AO/OTA CLASSIFICATION
PROXIMAL TIBIA DIAPHYSEAL #

4. • Forces exerted from the extensor mechanism, the hamstring and iliotibial
band
• Lack of endosteal fit from the nail
• Result of improper reduction:
– Malalignment in the form of valgus and procurvatum
– Reported in 44% to 84%
– Recommends against the use of IM implants in the treatment of these
fractures
WHY DIFFICULTY IN REDUCTION?

5. • Appropriate equipment
• Appropriate start and trajectory for the nail
• Obtaining and maintaining a reduction throughout the procedure
• Let’s go through the tips to overcome the pitfalls of IM nailing of proximal
tibia fracture!!!!!!
POTENTIAL PITFALLS

6. • Good knowledge about the local anatomy, pathoanatomy of the injury,
and implants and how they are designed
• Preparations for surgical techniques and instruments should be made
available according to the preoperative plan
– Setup and positioning
– Reduction methods
– Implants
– C-arm availability
PREOPERATIVE PLANNING

7. • Recognizing such patterns is integral to avoid malalignment
• Some injury patterns
– Fractures with large anterior cortical spikes with posterior comminution
– Ballistic injuries: they behave differently than standard shaft patterns
– Comminution on the lateral side is problematic: allows fracture to collapse in
valgus; and can lead to eccentric reaming
– Intra-articular extension of proximal shaft or metaphyseal fractures is also
important
• CT scan: characterizes the fracture morphology
– Allows for preoperative planning and strategic placement of block screws
TROUBLESOME INJURY PATTERNS

8. • HERZOG CURVE OF THE IM NAIL
• Henley et al noted that more distal the bend in the nail, more likely the
fracture displacement – WEDGE EFFECT
• IM devices with more proximal bend are more amenable to maintain the
fracture reduction
DESIGN OF MODERN IMPLANTS

9. • PROXIMAL LOCKING OPTIONS
• Single locking bolt: limited stability
• Advantage of using third proximal bolt
– Hansen et al – increased the axial stiffness by 61%
– Wolinsky et al – increased axial stiffness by 28% and torsional stiffness by
15% to 28%
DESIGN OF MODERN IMPLANTS

10. • SCREW ORIENTATION
• Coronal screws – Henley et al reported that in comminuted bone
increased stiffness was noticed with two coronal screws in comparison
with two oblique screws
• Medial-to-lateral oblique screws: places the common peroneal nerve at
risk, especially when applied approx. 30mm from the proximal end of the
implant
• Angular stable locking bolts: clinical utility yet to be proved
DESIGN OF MODERN IMPLANTS

11. • Obtain proper views to evaluate the location of the entry point and the
trajectory
• Proper AP view:
– Lateral edge of the tibia should bisect the fibular head
– Centered patella
– Excessive ER view of the knee will cause medial displacement of the
starting wire
– Excessive IR view of the knee will cause lateral displacement of the starting
wire
• Proper lateral view:
– Both femoral condyles should overlap each other
• Ease of imaging: semiextended position for nailing and suprapatellar
IMAGING

12. IMAGING

13. • According Tornetto et al, the ideal safe zone for IM nail placement was
located 9.1 ± 5mm lateral to the midline of the tibial plateau and 3mm
lateral to the center of the tibial tubercle
• Radiographic location:
– On AP view: point just medial to the lateral tibial spine
– On lateral view: proximal to the anterior edge of the articular margin
START POINT

14. • Tornetto et al introduced Semiextended nailing: medial parapatellar
arthrotomy with lateral subluxation of the patella was used to gain access
to the tibial portal
– Care to be taken to ensure integrity of the trochlear groove
• Modified medial miniarthrotomy: Ryan et al found no difference in knee
pain with this approach in comparison with the standard infrapatellar
approach
START POINT

15. • SUPRAPATELLAR TECHNIQUE:
• Major hurdle: obtaining posterior enough start point, as often the cannula
can be limiting as it is introduced into the relatively narrow patellofemoral
joint space
• Solution: delay placement of the cannula until after placement of the
starting guide-wire
START POINT

16. • Incision through the quadriceps tendon, followed by hyperextension of
the knee
• Place an Army-Navy retractor placed underneath the patella
• Safely pass the starting guidewire through the patellofemoral joint,
without causing any damage to the articular cartilage
• Remove the retractor and flex the knee to 40o to 50o
SUPRAPATELLAR TECHNIQUE

17. • Obtain the starting point and drive the guidewire through metaphysis of
the proximal tibia
• Place cannula over the starting guidewire with the knee again
hyperextended
• Ensure the trajectory of the guidewire remains within the middle of the
tibia, as lateral deviation can lead to accentuation of the valgus deformity
• Assessment of patellofemoral cartilage damage:
– Pre-nail and post-nail insertion arthroscopy
– 1 year MRI
SUPRAPATELLAR TECHNIQUE

18. SUPRAPATELLAR
TECHNIQUE

19. • Two approaches:
• Medial parapatellar approach
– At times, it is difficult to obtain proper starting point as lateral as necessary
• Patellar tendon split approach
– Remaining parallel to the anterior cortex is difficult as the patella prevents
posterior placement and a posterior to anterior trajectory of the guidewire
– Can be prevented with hyperflexion
INFRAPATELLAR TECHNIQUE

20. • As we move on to reaming, maintaining the entry point is also important
• Entry point may progressively migrate anteriorly when the sequential
reaming takes place
• This can avoided if the reaming is done only after placing the head of the
reamer is seated in the metaphysis and by manual removal of the reamer
through the starting hole
MAINTENANCE OF ENTRY POINT

21. • Wide clamps and periarticular clamps can be
used to maintain reduction
• Care must be taken that the placement of the
clamp does not cause significant trauma to
the soft tissue, especially anterior and lateral
group of muscles
• Alternative method:
– Place a small stab incision just off the lateral
crest of the tibia
– One tine of the clamp is then slid across the
bone laterally, leaving all musculature lateral
to the tine
CLAMPING

22. • Make sure that tines of the
clamp, rather than the jaws of
the tenaculum, are engaged
with the bone
• During reaming and nail
insertion, clamp can loosen
and/or shift from the applied
region. This can be prevented
by manual manipulation or
with Kocher clamped against
the ratcheting mechanism of
the clamp
CLAMPING

23. • They can be placed at multiple points to
effectively reduce the effective metaphyseal
space and increase the effective diameter of
the nail
• They are usually placed in the concavity of
the deformity in the proximal segment
• Or else, they are placed in a space where the
surgeon does not want the nail to occupy
BLOCKING SCREWS AND WIRES

24. • Effect of improperly placed screws
– Provide little or no correction of the deformity
– Can be too aggressive leading to inability to pass the reamer
– Increased hoop stresses that can propagate or cause a fracture
– Overreduction
• Typically the screws has to placed near or slightly within the previous nail
path in the concavity of the deformity and at 1 cm from the fracture
BLOCKING SCREWS

25. BLOCKING
SCREWS

26. • 2 mm or more in diameter
• Allows for more flexibility in terms of placement, with overly aggressive
placement often times not leading to overreduction but rather bending of
the wire
• If a single wire is inadequate to reduce the fracture, multiple wires can be
placed to assist the trajectory of the nail
BLOCKING WIRES

27. • A Kocher must be clamped to the wire closest to the skin to prevent its
migration (anterior to posterior) which may occur during reaming
• Alternatively, the reamer can be pushed forward without being spun
• All the wires should be removed after the placement of all the locking
bolts
BLOCKING WIRES

28. • Allows for unwavering traction and maintenance of length throughout the
duration of the procedure
• Schanz pin placement:
– Proximally, near the proximal tibial physeal scar in the mid-sagittal to slightly
posterior plane, which can dually serve as blocking screw to prevent apex
anterior angulation at the fracture
– Distally, along the distal physeal scar which is an optimum location for
prevention of interference with the path for the nail
• Preloading of the distractor: prevents valgus malalignment
UNIVERSAL DISTRACTOR

29. UNIVERSAL
DISTRACTOR

30. • Provides temporary reduction
• In case of open fractures: it reduces the biologic cost
• In closed fractures:
– Requires opening of the fracture to achieve reduction
– Associated with its own complications like stripping of the periosteum,
infection
• If unicortical plates are used
– 2.7mm plates and above are used with 6 to 8 mm screws
UNICORTICAL PLATES

31. • IM fixation of the proximal tibia fracture is complex and challenging
• Complication rate as high as 84%, malalignment being the most common
• Principles to be followed to reduce angular deformity
– Adequate imaging
– Optimal start point and trajectory for the implant
– Maintaining a reduction throughout the duration of the procedure
• Adjunctive techniques, discussed so far, to assist in the application of
these principles
CONCLUSION