Suprapatellar nailing of tibial fractures: surgical hints

Abstract

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.

Keywords: suprapatellar nail; surgical technique; tibia fracture.

FIGURE 1

Patient is positioned supine with a roll under the knee joint, which is bent 20-30 degrees. If the healthy leg is lowered from the horizontal position, the C-arm can be brought easily into position for a lateral view without moving the damaged leg.

FIGURE 2

Drawing of the midline of the patella and tibia simplifies the subsequent insertion of the guide pin in the top of the tibia. A 1.5-2 cm long skin incision is made 1 cm above the patella.

FIGURE 3

The quadriceps tendon is exposed, and a longitudinal incision is made.

FIGURE 4

A finger should be able to fit easily into the joint below the patella. If it is too tight it can be difficult to instrument the joint and consideration should be given to expanding entry with a partial medial or lateral arthrotomy.

FIGURE 5

The guide wire is introduced into the knee joint and is placed on top of the tibia. If it is aimed at the drawn midline of the tibia, placing the guide wire correctly at the first attempt often is successful.

FIGURE 6

Correct placement of the guide wire is checked under fluoroscopy in both planes.

FIGURE 7

Correct placement of the guide wire.

FIGURE 8

The trocar and drill sleeve are inserted along with an elastic nail insertion sleeve over the guide wire. This system allows the simultaneous fixation of the sleeves to the tibia plateau.

FIGURE 9

With the drill sleeve fixed to the tibia, an opening is made with a short reamer proximally in the tibia.

FIGURE 10

Reaming is performed through the drill sleeve as usual, while this is securely fixed to the top of the tibia. There may be a need for extra long reamers. Note the risk of compromising sterility when working close to the anesthesia barrier.

FIGURE 11

The nail is placed into the tibia over the guide wire and through the elastic nail insertion sleeve.

FIGURE 12

The nail is proximally locked using the system’s targeting device.

FIGURE 13

The end cap is inserted.

FIGURE 14

With a finger in the knee joint, the patella and femur are inspected for damage, and a final check is performed to make sure the nail cannot be felt inside the knee joint.

FIGURE 15

Before the end of the operation it is important to flush the knee joint carefully of blood and debris.