Suprapatellar nailing of fractures of the tibia
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Martin H. Hessmann1 · Michael Buhl1 · Chris Finkemeier2 · Amal Khoury3 · Rami Mosheiff4 · Michael Blauth5,6 1
Academic Teaching Hospital Fulda, Fulda, Germany Sutter Roseville Medical Center, Granite Bay, USA 3 Orthopedic Trauma Unit, Hadassah Ein Kerem Hospital, Hebrew University Medical Center, Jerusalem, Israel 4 Orthopedic Surgery Department, Hadassah Ein Kerem Hospital, Hebrew University Medical Center, Jerusalem, Israel 5 Department for Trauma Surgery, Medical University Innsbruck, Innsbruck, Austria 6 Trauma, CMF, Biomaterials, DePuy Synthes, Synthes GmbH, Zuchwil, Switzerland 2
Suprapatellar nailing of fractures of the tibia Introductory remarks Surgical approaches in intramedullary nailing of tibia fractures are important in order to insert implants through the correct entry point, to minimize damage to the intra-articular knee structures, and to allow for optimal fracture reduction and proper nail insertion. Classic approaches for tibial shaft fractures are the midline transtendinous and the medial or lateral paratendinous approaches. Whereas these approaches are appropriate in midshaft fractures, postoperative valgus, apex anterior or combined deformity occurs frequently in more proximal fractures [1, 2]. Knowledge about the correct starting point, use of nails with an appropriate design and more stable locking options as well the application of intraoperative reduction techniques contributed to decreased rates of postoperative malalignment. Recent studies however still report on malalignment in 15–40% of proximal tibial fractures treated with nails [3–6]. Malalignment of proximal tibial fractures mainly results from a deformity caused by the pull of the quadriceps tendon while flexing of the knee and by a mechanical conflict between the tip of the nail and the posterior cortex of the tibia during implant insertion. The patella also blocks on-axis entry of the nail in the sagittal plane (. Fig. 1a, b). Therefore, another common approach to the entry
point is through a medial parapatellar incision that leads to a slightly medial to lateral nail insertion (. Figs. 1c and 2). As the nail enters the intramedullary canal distal to the fracture, the proximal segment tilts into valgus (. Fig. 2). Finally there is a slight contribution to valgus by the resting tension of the anterior compartment muscles (. Fig. 3). Nailing of the tibia in a more extended position helps to avoid the complications associated with severe intraoperative knee flexion [7]. The technique, which has been described in 2010 by Gelbke [8], Jakma [9] and others, has been gaining increasing popularity in recent years since nailing of the tibia in a nearly straight limb position eases fracture manipulation and reduction. Image
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intensification becomes technically easier to perform. Significantly shorter fluoroscopy times have been reported with suprapatellar than with infrapatellar nailing [10–12]. Furthermore, the insertion angles of nails in this approach are more parallel (in the sagittal plane) to the longitudinal axis of the tibia than i
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