Minimally Invasive Approach for Tibial Nailing
Minimally Invasive Approach for Tibial Nailing
The minimally invasive approach for tibial nailing is used for the insertion of intramedullary nails used in the treatment of the following:
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Fresh tibial shaft fractures
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Pathologic tibial shaft fractures
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Delayed union and nonunion of tibial shaft fractures
Tibial nails do not have the wide variability in design seen in femoral nails. All tibial nails are angled at their upper end to allow insertion via an anterior route, and all tibial nails are straight when viewed in the anterior–posterior plane.
Position of the Patient
Two positions may be used for the insertion of tibial nails. Placing the patient on a traction table allows greater control of the fracture and easier distal locking. The free leg position allows greater knee flexion which makes nail insertion easier.
Traction Table
This is the most commonly used position. Place the patient supine on an operating table. Flex the hip to 60 degrees. Place a support behind the posterior aspect of the distal thigh. Take care not to place the support in the popliteal fossa where it will create pressure on the popliteal vein (Fig. 11-51; see Fig. 10-59).
Flex the knee to 100 to 120 degrees, and apply traction either by strapping the patient’s foot to the sole of a traction boot or using a Steinmann pin inserted through the os calcis. A conventional traction boot extends 5 to 8 cm above the heel. The boot will prevent the insertion of distal locking bolts because the required skin incision will be covered by the boot and it therefore should not be used.
Some authors feel that the use of a tourniquet is contraindicated if reaming of the tibial shaft is to be carried out arguing that the lack of convective blood flow will make thermal damage to the bone more likely. It is likely that any tourniquet effect is very slight and that the key to prevention of thermal necrosis lies with the judicious use of sharp
reamers.15 Note that minimal traction is required to reduce a fresh tibial shaft fracture.
Place the contralateral leg in a support with the hip flexed and abducted and the knee flexed (see Fig. 11-51). Ensure that good quality radiographs of the entry point, fracture site, distal and proximal locking areas can be obtained using a C-arm before prepping and draping.
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Figure 11-51 Traction table position. Flex the hip to 60 degrees. Flex the knee to 100 to 120 degrees, and apply traction by strapping the foot to the sole of a traction boot. Place the opposite leg in a support with the hip flexed and abducted and the knee flexed.
Free Leg Position
Place the patient supine on an operating table. Remove the end of the table, and allow the injured knee to flex over the end of the table. Place the contralateral leg in a support with the hip flexed and abducted and the knee flexed. Do not use a tourniquet (Fig. 11-52).
Landmark and Incision
Landmarks
Palpate the patella on the anterior aspect of the knee. The patellar tendon is felt as a resistance extending from the inferior pole of the patella to the tibial tubercle.
Incision
Make a 5-cm incision on the anterior aspect of the tibia, beginning at the inferior border of the patella and extending the incision down to just above the tibial tubercle (Fig. 11-53). This incision should overlie the medial border of the patellar tendon.
Internervous Plane
There are no internervous planes involved in this approach.
Superficial Surgical Dissection
Incise the subcutaneous fat and fibrous tissue arising from the medial aspect of the patellar tendon in the line of the skin incision. Numerous small arterial vessels are usually encountered and will need to be coagulated. Identify the medial border of the patellar tendon and incise this fascia longitudinally along the border (Fig. 11-54).
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Figure 11-52 Free leg position. Place the patient supine on the operating table. Remove the end of the table. Allow the injured knee to flex over the end of the
table. Place the contralateral leg in a support with the hip flexed and abducted and the knee flexed.
Deep Surgical Dissection
Retract and mobilize the patellar tendon laterally to expose a small bursa between the tendon and the anterior aspect of the tibia—the deep infrapatellar bursa (Fig. 11-55). The precise entry point of the nail into the medullary canal of the tibial shaft can be calculated preoperatively by overlaying a template of the nail on the anterior–posterior radiograph of the injured tibia. In the frontal plane the entry point lies in the axis of the medullary canal of the tibia. In the sagittal plane the entry point of the nail lies at the very proximal end of the tibia at the junction of the anterior and superior aspects of the bone. Note that this entry point, although on the superior aspect of the tibia, is extrasynovial (Fig. 11-56). The entry point for the nail must be confirmed radiographically (in the operating room) in both the anterior–posterior and lateral planes before entry is made.
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Figure 11-53 Make a 5-cm long incision overlying the medial edge of the patellar tendon.
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Figure 11-54 Deepen the skin incision to expose the medial edge of the patellar tendon.
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Figure 11-55 Incise the fascia on the medial edge of the patellar tendon and retract the tendon laterally.
Dang
Nerves and Vessels
The infrapatellar branch of the saphenous nerve is frequently damaged in this approach. It is impossible to preserve all the branches of the nerve, and patients should be warned that an area of numbness is likely following this surgical approach (see Fig. 10-35).
If a traction table is used and the thigh rest is placed within the popliteal fossa, compression of the popliteal veins can result. This can increase the risk of deep vein thrombosis.
Ligaments and Meniscus
If the entry point is too far posterior, damage to the tibial insertion of the anterior cruciate ligament and the anterior horn of the medial meniscus may occur (Fig. 11-57).
Deformity
If the entry point is too far medial, a valgus deformity will be created at the fracture site in proximal fractures. If the entry point is too far lateral, a varus deformity will be created at the fracture site in proximal fractures.
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Figure 11-56 View of the superior surface of the tibia, showing the entry point of the nail. The insertion point is extrasynovial, lying anterior to the tibial insertion of the anterior cruciate ligament and lateral to the anterior horn of the medial meniscus.
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Figure 11-57 Correct and incorrect insertion points. Note that if the entry point is too far posterior then damage to the insertion of the anterior cruciate ligament on the tibia will occur. An entry point that is too far anterior will cause splintering of the anterior cortex of the tibia on nail insertion.
Bone
If the entry point is too far inferior on the anterior surface of the tibia, then
splitting of the anterior cortex of the tibia may occur on nail insertion (see Fig. 11-57).
Nail insertion is very difficult if the knee is not flexed to beyond 90 degrees due to pressure of the nail on the anterior aspect of the patella. Such pressure may be sufficient to produce a compression lesion of the patellofemoral joint or even transient subluxation of the patella, producing damage to the articular cartilage of the patella. For that reason, many surgeons prefer a free leg position, which allows greater degrees of flexion than can be easily obtained using a traction table.
How to Enlarge the Approach
This approach gives excellent visualization of the entry point of the nail but has no other uses. It cannot be usefully enlarged.