25.1 Introduction

Tibia fractures are the most common long-bone fractures. ³ These injuries have traditionally been treated with casting, plating, or intramedullary nailing. To appropriately treat tibia fractures, the treating surgeon must have a thorough understanding of the anatomy, challenges, and complications that accompany them. The anterior tibial artery can be damaged during the initial injury as it passes through the interosseous membrane: damage to this artery may result in increased interstitial pressure, poor blood flow, and eventually compartment syndrome. ³ As the entire anteromedial surface of the tibia is subcutaneous, open fractures are common. Closed reduction can often be difficult, and the treating surgeon must understand the muscular and tendinous forces that create fracture deformation. In fact, mal-reduction is not uncommon and malunion occurs in up to 37% of tibial nailing procedures; however, nonunion is relatively uncommon. ² In the appropriate clinical setting, intramedullary tibial nailing is an effective method for treating tibia fractures as it minimizes soft tissue insult, provides a biomechanical advantage, and allows for early weight bearing.

25.2 Preop

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  Surgical table. Radiolucent Jackson trauma table

  
  
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  Patient position. Supine. Place a bump under the hip of the operative side to counteract the natural external rotation of the leg. A radiolucent triangle is used to maximize knee flexion, to make it easier to obtain a correct starting point.

  
  
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  Operating room setup. The C-arm should be positioned on the contralateral side and perpendicular to the operative table. The overhead operating room lights should be moved away from the area directly over the patient’s injured extremity, as they will be in the way of guidewire and reamers. A step stool can be used to improve the surgeon’s position during reaming.

  
  
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  Surgical prep. Sterilely prep the entire leg, from the proximal thigh to the foot. If the thigh is draped too distally, the drapes may limit knee flexion. Prepping through the foot allows the surgeon to judge intraoperative length, alignment, and rotation of the injured extremity.

  
  
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  Patient exam. Perform a complete neurovascular and motor exam, which includes the assessment of dorsalis pedis and posterior tibial pulses, sensory function of the tibial, sural, saphenous, superficial and deep peroneal nerves, and motor function of the extensor hallucis longus and tibialis anterior. Inspect the anterior tibial skin for open wounds or skin breakdown, as there is little subcutaneous tissue protecting the skin from sharp fracture fragments. Often, anteriorly displaced tibial shaft fractures create open fractures or compromise the thin anterior skin.

25.3 Approach

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  In the supine position with the knee flexed over the radiolucent triangle, mark the borders of the patella and the medial and lateral borders of the patellar tendon.

  
  
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  Multiple approaches are used for intramedullary tibial nailing; medial and lateral parapatellar tendon, transpatellar tendon, and suprapatellar. There is no difference in postoperative knee pain, and this chapter will focus on the transpatellar approach, as it is one of the most commonly used. ⁴

  
  
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  For the transpatellar approach, make a straight incision through the skin and subcutaneous tissue over the center of the patellar tendon from the inferior pole of the patella and extend it, approximately 3–4 cm in length.

  
  
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  Note the medial and lateral borders of the patellar tendon and make a vertical, full-thickness incision in the midline of the tendon in the same length as the skin incision. Avoid injuring the menisci, which will be located at the inferior portion of the transpatellar incision. ¹

25.4 Initial Guidewire Insertion and Entry Reaming

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  The starting guidewire is inserted freehand through the incised patellar tendon, and the starting point is identified.

  
  
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  The correct starting point is confirmed using anteroposterior (AP) and lateral C-arm fluoroscopic images. In the AP image, the guidewire should be placed just medial to the lateral tibial spine. In the lateral image, it should be located just anterior to the articular plateau (▶Fig. 25.1).

  
  
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  The guidewire must be inserted in line with the anatomic axis of the tibia to avoid eccentric reaming of the tibia. It can be challenging to achieve the appropriate anterior direction in the sagittal plane. To achieve the appropriate sagittal vector, the knee must be hyperflexed and the wire typically must be pushed against the patella. This alignment is confirmed with AP and lateral C-arm images prior to driving the guidewire forward. In the sagittal plane, the wire should be nearly parallel with the anterior tibial cortex.

  
  
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  Using a wire driver, the wire is then inserted approximately 8 to 10 cm into the proximal tibial metaphysis.

  
  
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  The cannulated opening reamer and soft tissue protector is then introduced over the guidewire onto the tibial cortex.

  
  
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  It is imperative that the knee remains hyperflexed during the opening reaming. If not, the entry reaming hole will become displaced anteriorly and violate the proximal anterior cortex. The reamer is taken to the level of the guidewire tip and both the reamer and the guidewire are subsequently removed from the tibia.