Pearls and pitfalls with im nailing of proximal tibia fractures

Pearls and pitfalls with im nailing of proximal tibia fractures by Dr Bipul Borthakur

1. PEARLS AND PITFALLS WITH im NAILING OF PROXIMAL TIBIA FRACTURES dr. bipul borTHakur professor & HOD, dept of orthopaedics , smch

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 I ntra-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 technique 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 40 o to 50 o 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 d eformity 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 S chanz 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

32. THANK YOU