Arthroscopically Assisted Suprapatellar Tibial Nail Removal

Abstract

Intramedullary nailing remains the most popular and preferred method of fixation for tibial shaft fractures. The infrapatellar approach through the patellar tendon has long been considered the gold standard. However, the suprapatellar approach has gained popularity because of the advantages of being easier to perform when treating proximal shaft and metaphyseal fractures and there being less postoperative anterior knee pain. Despite increased use of this approach, the removal of the implant from the same suprapatellar approach is tricky, and in most cases, the removal is performed through a new transpatellar tendon approach. This article describes arthroscopically assisted suprapatellar tibial nail removal using the same approach and instrumentation of the nail insertion. The technique has the advantage of preserving the patellar tendon without causing secondary damage to it. Through arthroscopy, direct visualization of the patellofemoral joint aids in preventing possible cartilage injury. Moreover, any associated intra-articular lesions can be diagnosed and addressed.

Fig 1

Patient in supine position, right knee; anterolateral viewing portal. After identification of the tibial nail entry site, scar tissue may be debrided. (A) A radiofrequency ablation shaver is used to debride the synovial tissue around the insertion point. (B) An aggressive shaver is used to remove bony overgrowth (green arrow) and allow adequate vision of the tibial nail. (C) View of tibial nail after synovial tissue and bony overgrowth removal.

Fig 2

Patient in supine position, right knee; anterolateral viewing portal. A nail extractor is inserted via the suprapatellar wound and is passed via the lateral parapatellar space (blue arrow) to avoid patellofemoral chondral damage, with the viewing scope directed to it (orange arrow). After its entrance, the arthroscope is redirected medially to observe the tibial nail insertion point.

Fig 3

Patient in supine position, right knee; anterolateral viewing portal. (A) After the removal of the nail’s end cap, peripheral bone ingrowth is debrided, allowing for the entrance of a universal rod. (B) After the rod is threaded and attached to the nail, removal of the interlocking screws can be performed.

Fig 4

Patient in supine position, right knee; anterolateral viewing portal. (A) A 20-mm incision (green arrow) is performed after anteromedial and anterolateral portals are placed. (B) After distal and proximal interlocking screw removal, the nail may be extracted (blue arrow).