n trauma updateSection Editors: David J. Hak, MD, MBA & Philip F. Stahel, MD

DECEMBER 2015 | Volume 38 • Number 12 751

Advances in Intramedullary Nailing: Suprapatellar Nailing of Tibial Shaft Fractures in the Semiextended PositionBoris A. Zelle, MD; Guilherme Boni, MD; David J. Hak, MD, MBA, FACS; Philip F. Stahel, MD, FACS

Tibial shaft fractures repre-sent a relatively common

injury, are typically encoun-

tered in young patients, and are the result of high-energy trauma.1,2 Intramedullary nail

fixation remains the treatment of choice for displaced and un-stable tibial shaft fractures in the adult population. Intramed-ullary nail fixation provides the advantage of minimal surgical dissection with preservation of the extraosseous blood supply to the fracture. The indications for intramedullary nailing be-come more limited for frac-tures involving the proximal and distal metaphysis. Recent advances in nail design and reduction techniques have expanded the indications for intramedullary nail fixation to more proximal as well as more distal tibia fractures in-volving the metaphyseal area. However, proximal third tibial shaft fractures in particular seem to be at risk for valgus and apex anterior deformities.3 Establishing an anatomic start-ing point appears to be crucial in these fracture patterns. Su-prapatellar nailing in the semi- extended position has recently been suggested as a safe and effective surgical technique. The technique allows for es-

tablishment of an appropriate starting point, and the semi- extended position facilitates the fracture reduction of apex anterior deformities. Prelimi-nary clinical data have shown promising results with a low rate of postoperative anterior knee pain.4,5 This article re-views the current concepts of suprapatellar nailing of tibial shaft fractures in the semi- extended position.

InItIal EvaluatIon and ManagEMEnt

Patients with high-energy tibial shaft fractures must be evaluated for associated inju-ries according to Advanced Trauma Life Support (ATLS) guidelines. From the orthopedic standpoint, the injured lower extremity must be thoroughly examined. A detailed neuro-vascular examination must be documented. Associated open fractures must be promptly identified. Patients must be carefully checked for acute compartment syndrome, and serial examinations are war-

The authors are from the Department of Orthopaedic Surgery (BAZ), Division of Orthopaedic Traumatology, University of Texas Health Science Center at San Antonio, San Antonio, Texas; the Department of Orthopaedics and Traumatology (GB), Federal University of São Paulo, São Paulo, Brazil; and the Department of Orthopaedics (DJH, PFS), Denver Health Medical Center and University of Colorado School of Medicine, Denver, Colorado.

Dr Boni has no relevant financial relationships to disclose. Dr Zelle has received personal fees from AO North America. Dr Hak is a paid consultant for Invibio and KurosBiosurgery. Dr Stahel has received grants from Stryker and lecture fees from DePuy Synthes.

Correspondence should be addressed to: Boris A. Zelle, MD, Depart-ment of Orthopaedic Surgery, Division of Orthopaedic Traumatology, Uni-versity of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MC-7774, San Antonio, TX 78229 (zelle@uthscsa.edu).

doi: 10.3928/01477447-20151119-06

Abstract: Reamed locked intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Supra-patellar tibial nailing in the semiextended position has been suggested as a safe and effective surgical technique that al-lows mitigating certain challenges of the standard subpatellar approach. Suprapatellar nailing seems to facilitate achieving and maintaining fracture reduction, particularly in proximal third tibia fractures. Preliminary investigations have suggest-ed that this technique is associated with a low rate of compli-cations, including a reduced incidence of postoperative ante-rior knee pain. Further clinical investigations are necessary to establish overall complication rates and long-term subjective outcomes. [Orthopedics. 2015; 38(12):751-755.]

752 Copyright © SLACK inCorporAted

n trauma update

ranted. The risk of associated compartment syndrome has been reported to be as high as 11.5%.6 In particular, younger patients with high-energy tibial shaft fractures seem to be at risk for associated compartment syndrome.6,7

The radiographic evalua-tion of tibial shaft fractures re-quires anteroposterior and lat-eral radiographs of the injured tibia. In addition, dedicated radiographs of the adjacent knee and ankle joints are man-datory. If an associated tibial plateau fracture is suspected, a computer tomography scan may provide useful informa-tion for the further treatment of the injury. Similarly, computer tomography scans of the ankle may be useful for identify-ing associated noncontiguous ankle injuries or for detecting extension of the tibial shaft fracture into the tibial plafond.8

SurgIcal conSIdEratIonSTibial Nail Starting Point

Establishing an appropri-ate starting point plays a key role in intramedullary nailing procedures. Several anatomic investigations have contrib-uted to understanding of the ideal starting point for in-tramedullary nailing of tibia fractures.9-11 In most patients, the ideal starting point lies at the anterior edge of the tibial plateau and just medial to the lateral tibial spine. Tornetta et al11 further reported on a “safe zone” with a width of 22.9±8.9 mm that allows for nail inser-tion without risk of damage to adjacent intra-articular structures. Traditionally, the starting point is established

through an infrapatellar ap-proach that allows access to the proximal tibia by either splitting the patellar tendon (transtendinous approach) or dissecting just adjacent to the patellar tendon (paratendinous approach). This traditional technique requires that the knee be resting over a radio-lucent triangle and in a flexed or fully flexed position. The positioning, however, may exaggerate apex anterior de-formities that are frequently complicating the treatment of proximal third tibia fractures. Moreover, the infrapatellar starting point has been report-ed to be associated with a high rate of postoperative anterior knee pain.12 Therefore, the use of a starting point that has the potential to facilitate the frac-ture reduction and at the same time minimize the risk of post-operative anterior knee pain seems desirable.

Nailing in the semiex-tended position has recently gained increased attention in the orthopedic literature.4,5,13,14 Tornetta and Collins15 suggest-ed tibial nailing in the semi- extended position using a me-dial parapatellar approach as a method to avoid apex anterior deformities. Recent reports have adopted this concept, suggesting a suprapatellar por-tal and nail insertion through the patellofemoral joint with the knee in the semiextended position.4,5 During the past few years, specific instrumen-tation has been developed for this technique with the goal of allowing the proce-dure to be performed in a soft tissue–friendly fashion and

with minimal damage to the surrounding structures.

Surgical TechniqueSuprapatellar nailing is

performed with the knee flexed in approximately 15°. An approximately 3-cm in-cision is made about 1 to 2 fingerbreadths above the pa-tella. The quadriceps tendon is split longitudinally and the patellofemoral joint is en-tered. A cannula system with a blunt trochar is then inserted through the patellofemoral joint and advanced to the ap-proximate starting point at the junction of the anterior cor-tex of the proximal tibia and the articular surface (Figure 1). The starting point is es-tablished under fluoroscopic guidance with a 3.2-mm guide pin, respecting the anatomic landmarks as described above. A multiholed guide pin sleeve may allow for fine adjustments of the starting point (Figure 2). Following confirmation of the appropriate starting point using anteroposterior and lat-eral fluoroscopic images, an opening reamer can be insert-ed through the cannula sys-tem. The K-wire is retrieved and a ball-tipped guidewire is inserted through the cannula system into the proximal frac-ture fragment. The ball-tipped guidewire is advanced across the fracture site to the level of the knee joint. The remaining surgical procedure, including the reaming process and inser-tion of the nail, is performed through the cannula system, allowing for appropriate pro-tection of the surrounding soft tissues and intra-articular

structures. At the conclusion of the surgical procedure, a thorough irrigation of the sur-gical site is advised to avoid retained debris within the knee joint. An appropriate repair of the longitudinal split within the quadriceps tendon is per-formed. The postoperative treatment protocol is identical to established protocols of tib-ial nailing, and early range of motion exercises of the knee and ankle are encouraged.

Potential Advantages and Disadvantages

Semiextended tibial nail-ing through a suprapatellar portal offers several potential advantages. It potentially fa-cilitates the fracture reduction, especially in proximal tibia fractures with an apex anterior deformity. In these types of in-juries, the use of a radiolucent triangle and hyperflexion of the knee may exaggerate the existing deformity, whereas the semiextended position may eliminate the extension force of the quadriceps and may greatly facilitate the reduction of the apex anterior angula-tion. Moreover, the leg resting in near extension on the oper-ating room table may ease the maneuvering of the leg during surgery and facilitate the access of the fluoroscopic image in-tensifier. In addition, associated soft tissue injuries involving the infrapatellar area may make it undesirable to place a surgi-cal incision in this area; the su-prapatellar portal may provide a reasonable alternative in these situations (Figure 3).

Despite these potential advantages, concern remains

n trauma update

regarding associated injuries to the patellofemoral carti-lage and the long-term conse-quences associated with this. In a cadaveric study, Gelbke et al14 measured the peak contact pressures in the patellofemoral joint during suprapatellar and infrapatellar nailing. Although the peak pressures appeared higher with the suprapatel-lar nailing technique, Gelbke et al14 reported that the peak pressures observed were well below the threshold deter-mined to be detrimental to the articular cartilage.

outcoMESSatisfactory outcomes and

reproducible results can be achieved with intramedullary nail fixation of tibial shaft fractures. The reported union rates of intramedullary tibial nailing vary among studies. With contemporary implants and appropriate surgical tech-niques, union rates above 90%

can be expected.16 Despite these favorable union rates, the functional outcomes following intramedullary nail fixation leave room for improvement. In particular, postoperative knee pain seems to be a limit-ing factor during the recovery process.12,17-21 A review of the literature with pooled data from publications including the years 1990 until 2005 sug-gested that postoperative knee pain may occur in approxi-mately 47% of patients follow-ing intramedullary nailing.12 Currently, the exact etiology of postoperative anterior knee pain following tibial nailing is not fully understood. Several contributing factors have been suggested, such as traumatic and iatrogenic damage to intra-articular structures, inju-ries to the infrapatellar branch of the saphenous nerve, thigh muscle weakness secondary to pain-related neuromuscular reflex inhibition, fat pad fibro-

DECEMBER 2015 | Volume 38 • Number 12 753

Figure 1: Schematic drawing (A; © UTHSCSA) and intraoperative image (B) showing the suprapatellar starting point through a longitudinal split of the quadriceps tendon. Intraoperative fluoroscopic lateral (C) and anteroposterior (D) views of the starting point.

A

B

C D

Figure 2: A multiholed cannula (A) allows for fine adjustments (B) of the start-ing point.

A B

754 Copyright © SLACK inCorporAted

n trauma update

sis leading to impingement, reactive patellar tendonitis, bending strain exerted by the nail on the proximal part of the tibial bone, and proximal pro-trusion of the nail.10,12,18,22-24 It must be assumed that the etiol-ogy of postoperative anterior knee pain may be multifacto-rial and that any of the above named factors may potentially contribute to this phenomenon.

Regarding postoperative an-terior knee pain, intriguing re-sults have been reported in pre-liminary clinical investigations of suprapatellar tibial nailing in the semiextended position. In a prospective clinical study in-cluding 56 consecutive patients undergoing suprapatellar tibial nailing, Sanders et al5 did not identify significant sequelae af-fecting the patellofemoral carti-lage as per magnetic resonance imaging and arthroscopic eval-uations. In particular, it was noteworthy that in their series,

Sanders et al5 did not identify any patients with postoperative anterior knee pain at a mini-mum of 12 months of follow-up. However, 1 patient reported peri-incisional pain around the knee. In a retrospective cohort study, Jones et al4 reported on 38 patients undergoing supra-patellar nailing vs 36 patients undergoing infrapatellar nail-ing. Patients were followed for a minimum of 12 months. Jones et al4 did not identify any statistically significant differ-ences regarding anterior knee between patients undergoing suprapatellar vs infrapatellar nailing. However, Jones et al4 observed a trend toward greater symptomatic knee pain in the infrapatellar group. Moreover, significantly better reductions and more accurate starting points were found in the supra-patellar nailing group.4

These promising data sug-gest that appropriate clinical and radiographic outcomes can be achieved with supra-patellar nailing in the semi- extended position. The tech-nique allows for establishment of an accurate starting point, may facilitate fracture reduc-tion, and appears to be asso-ciated with a relatively low rate of anterior knee pain. Al-though these preliminary data seem encouraging, the theoret-ical concern remains of iatro-genic cartilage damage to the patellofemoral joint associated with this procedure.13,14 There-fore, larger clinical investiga-tions with long-term follow-up are necessary to substantiate the impact of suprapatellar nailing on long-term patello-femoral pain.

concluSIonReamed locked intramedul-

lary nailing remains the stan-dard treatment for displaced tibial shaft fractures.16 A cor-rect starting point remains a crucial part of the surgical pro-cedure.25 Suprapatellar nailing in the semiextended position offers an alternative to the tra-ditional infrapatellar approach.5 Specific instrumentation with a cannula system allows for nail insertion in a safe fashion and minimizes the risk of iatrogenic damage to intra-articular struc-tures. Accurate starting points can be established using this technique. The semiextended position may facilitate frac-ture reduction in particular in proximal third tibia fractures. Preliminary clinical data sug-gest a low rate of postoperative anterior knee pain.4,5 However, concern remains regarding iat-rogenic damage to the patello-femoral joint. Trials are needed evaluating the long-term func-tional outcomes associated with this new, innovative tech-nique.

rEfErEncES 1. Kaye JA, Jick H. Epidemiol-

ogy of lower limb fractures in general practice in the United Kingdom. Inj Prev. 2004; 10(6):368-374.

2. Bhandari M, Guyatt G, Tor-netta P III, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 2008; 90(12):2567-2578.

3. Hiesterman TG, Shafiq BX, Cole PA. Intramedullary nailing of extra-articular proximal tibia fractures. J Am Acad Orthop Surg. 2011; 19(11):690-700.

4. Jones M, Parry M, Whitehouse M, Mitchell S. Radiologic outcome and patient-reported

function after intramedullary nailing: a comparison of the retropatellar and infrapatellar approach. J Orthop Trauma. 2014; 28(5):256-262.

5. Sanders RW, DiPasquale TG, Jordan CJ, Arrington JA, Sagi HC. Semiextended intramedul-lary nailing of the tibia using a suprapatellar approach: ra-diographic results and clinical outcomes at a minimum of 12 months follow-up. J Orthop Trauma. 2014; 28(5):245-255.

6. McQueen MM, Duckworth AD, Aitken SA, Sharma R, Court-Brown CM. Predictors of compartment syndrome after tibial fracture. J Orthop Trau-ma. 2015. Epub ahead of print.

7. Park S, Ahn J, Gee AO, Kuntz AF, Esterhai JL. Compart-ment syndrome in tibial frac-tures. J Orthop Trauma. 2009; 23(7):514-518.

8. Purnell GJ, Glass ER, Altman DT, Sciulli RL, Muffly MT, Alt-man GT. Results of a computed tomography protocol evaluat-ing distal third tibial shaft frac-tures to assess noncontiguous malleolar fractures. J Trauma. 2011; 71(1):163-168.

9. Buehler KC, Green J, Woll TS, Duwelius PJ. A technique for intramedullary nailing of proxi-mal third tibia fractures. J Or-thop Trauma. 1997; 11(3):218-223.

10. McConnell T, Tornetta P III, Tilzey J, Casey D. Tibial por-tal placement: the radiographic correlate of the anatomic safe zone. J Orthop Trauma. 2001; 15(3):207-209.

11. Tornetta P III, Riina J, Geller J, Purban W. Intraarticular ana-tomic risks of tibial nailing. J Orthop Trauma. 1999; 13(4): 247-251.

12. Katsoulis E, Court-Brown C, Giannoudis PV. Incidence and aetiology of anterior knee pain after intramedullary nailing of the femur and tibia. J Bone Joint Surg Br. 2006; 88(5):576-580.

13. Eastman J, Tseng S, Lo E, Li CS, Yoo B, Lee M. Retropatel-lar technique for intramedul-lary nailing of proximal tibia fractures: a cadaveric assess-ment. J Orthop Trauma. 2010; 24(11):672-676.

14. Gelbke MK, Coombs D, Pow-

Figure 3: Intraoperative image show-ing the soft tissue injury to the in-frapatellar area as an indication for suprapatellar nailing in the semi- extended position.

n trauma update

ell S, DiPasquale TG. Supra-patellar versus infra-patellar intramedullary nail insertion of the tibia: a cadaveric model for comparison of patello-femoral contact pressures and forces. J Orthop Trauma. 2010; 24(11):665-671.

15. Tornetta P III, Collins E. Semiextended position of intra-medullary nailing of the proxi-mal tibia. Clin Orthop Relat Res. 1996; 328:185-189.

16. Duan X, Al-Qwbani M, Zeng Y, Zhang W, Xiang Z. Intramed-ullary nailing for tibial shaft fractures in adults. Cochrane

Database Syst Rev. 2012; 1:CD008241.

17. Court-Brown CM, Gustilo T, Shaw AD. Knee pain after in-tramedullary tibial nailing: its incidence, etiology, and out-come. J Orthop Trauma. 1997; 11(2):103-105.

18. Hernigou P, Cohen D. Proximal entry for intramedullary nailing of the tibia: the risk of unrecog-nised articular damage. J Bone Joint Surg Br. 2000; 82(1):33-41.

19. Keating JF, Orfaly R, O’Brien PJ. Knee pain after tibial nail-ing. J Orthop Trauma. 1997;

11(1):10-13.

20. Koval KJ, Clapper MF, Brum-back RJ, et al. Complications of reamed intramedullary nailing of the tibia. J Orthop Trauma. 1991; 5(2):184-189.

21. Lefaivre KA, Guy P, Chan H, Blachut PA. Long-term follow-up of tibial shaft fractures treat-ed with intramedullary nail-ing. J Orthop Trauma. 2008; 22(8):525-529.

22. Devitt AT, Coughlan KA, Ward T, et al. Patellofemoral contact forces and pressures during in-tramedullary tibial nailing. Int Orthop. 1998; 22(2):92-96.

23. Mochida H, Kikuchi S. Injury to infrapatellar branch of saphe-nous nerve in arthroscopic knee surgery. Clin Orthop Relat Res. 1995; 320:88-94.

24. Nyland J, Bealle DP, Kaufer H, Johnson DL. Long-term quadri-ceps femoris functional deficits following intramedullary nail-ing of isolated tibial fractures. Int Orthop. 2001; 24(6):342-346.

25. Flierl MA, Stahel PF, Morgan SJ. Surgical fixation of extra- articular tibia fractures: tips and tricks. Minerva Orthop Trau-matol. 2009; 60:527-540.

DECEMBER 2015 | Volume 38 • Number 12 755