Abstract
The suprapatellar approach for intramedullary tibial nailing has become widely accepted
over the past decade. A round sleeve is passed beneath the patella to protect the surface
of the patellofemoral joint (PFJ). However, the round sleeve cannot be easily stabilized
in the PFJ because it does not conform to the shape of the patellar apex. Consequently, we
produced a heart-shaped sleeve to simplify the insertion of the entry sleeve during the
suprapatellar approach. Using the new sleeve, the following procedure is used: (1) make a
longitudinal 4 cm skin incision proximal to the patella to reach the PFJ, (2) insert the
guide pin manually to the ventral edge of the tibial plateau, (3) insert the cannulated
trocar along the guide pin, (4) insert the heart-shaped sleeve along the cannulated
trocar, (5) remove the cannulated trocar, (6) ream the entry point through the
heart-shaped sleeve. Then, continue insertion of the nail in the standard manner. Among 44
patients (29 men, mean age 45.6 years, range 26–87 years) with tibial fractures treated
between 2010 and 2015, the first 18 consecutive cases were performed using a round sleeve
and the rest were performed using the heart-shaped sleeve. The surgery time until entry
reaming commenced was 8.9 min (range 6–12 min) using the round sleeve and 6.2 min (range
3–12 min) using the heart-shaped sleeve (P < 0.05). The heart-shaped
sleeve is easily stabilized in the PFJ and greatly simplifies the intramedullary nailing
of tibial shaft fractures using the suprapatellar approach.
Introduction
Intramedullary nailing is widely accepted as the standard surgical procedure in treating
tibial fractures. Intramedullary nails are most commonly inserted using the infrapatellar
transtendon approach with the patient’s hip and knee flexed. However, this approach can lead
to problems achieving adequate X-ray monitoring, and an assistant surgeon is required to
maintain the appropriate reduction while the nail is inserted. Furthermore, this procedure
is sometimes associated with anterior knee pain.
Since Cole1 (2006) and Reucker2 (2009) reported the technique for a
suprapatellar approach (SPA) with the knee in a semi-extended position to overcome these
problems, SPA has been widely adopted. SPA, simplifies the fracture reduction and
facilitates intraoperative C-arm visualization and nail insertion. Although invasion to the
patellofemoral joint (PFJ) articular surface during SPA does not usually result in major
damage clinically,3,4 the surgeon must exercise care in protecting the
patellofemoral articular surface because the long-term outcomes of the procedure have not
yet been established.
In SPA, insertion of the trocar into the PFJ is often troublesome,5 because the round trocar is incompatible with
the shape of the ridge of the patella (Fig. 1A,
B). Even if the trocar is inserted properly, if the patella should subluxate
laterally (or medially), the restoring force of the patellar thrust will move the sleeve
laterally (Fig. 1C, D, Animation1). Because the
entry point determines the position of the nail in the intramedullary nailing, it is crucial
to locate the entry hole in the correct position. Consequently, any instability of the
trocar is a cause of great concern during the operation. To solve this problem and to
simplify insertion of the entry sleeve when using SPA, we developed a PFJ protection sleeve
that is heart shaped in cross section (Fig. 2),
and additionally produced a cannulated trocar. The heart-shaped sleeve was designed
considering the shape of the joint surface, the patellar facet angle, and the sulcus angle.
The tip of the sleeve is gradually tapered so as not to damage the joint surface during
insertion. Using a guide-pin-first approach with the heart-shaped sleeve will simplify the
whole procedure and also help to reduce fracture malalignment.
SPA Surgical Techniques Using the Heart-Shaped Sleeve: A Guide-Pin-First Method
In conventional SPA, a round sleeve and trocar is inserted before placing the guide pin;
however, inserting the sleeve is not easy.6,7 In our novel
method, we first carefully insert the guide pin, and then the following procedure can be
performed without any major difficulties (Animation2):
-
(1) Make a 4-cm longitudinal skin incision, one finger breadth above the superior pole
of the patella.
-
(2) Sharply dissect the patellofemoral compartment of the quadriceps to the joint
capsule.
-
(3) Carefully insert a 3.2-mm guide pin through the PFJ manually, while protecting the
articular surface of patella with the finger (Fig.
3A). Although the guide pin is usually guided to the appropriate starting point
by the shape of the femoral trochlear groove, the entry point should be confirmed using
biplanar C-arm imaging. [In the anteroposterior (AP) view, the entry point is in line
with the axis of the intramedullary canal and with the lateral tubercle of the
intercondylar eminence. In the lateral view, the entry point is at the ventral edge of
the tibial plateau (Fig. 4).]
-
(4) After definitive placement of the guide pin, insert the cannulated trocar over the
guide pin (Fig. 3B).
-
(5) Insert the heart-shaped sleeve over the trocar (Fig. 3C).
-
(6) Remove the cannulated trocar (Fig.
3D).
-
(7) Insert the entry reamer through the heart-shaped sleeve along the guide pin, and
create the entry hole for the nail (Fig.
3E).
After creating the entry hole, the nail is inserted in the standard manner. The trocar and
the heart-shaped sleeve should be gently inserted and carefully located during the entire
procedure so as not to damage intra-articular chondral surfaces of the PFJ.
Comparison of Surgery Times Using theHeart-Shaped Sleeve and the Round Sleeve
The study was approved by the ethics committee of Keio University Hospital and Fujita
Health University. Among 44 patients (29 men, mean age 45.6 years, range 26–87 years) with
tibial fractures treated between 2010 and 2015, the first 18 consecutive cases were
performed using a round sleeve and the rest were performed using the heart-shaped sleeve.
The surgery time until entry reaming commenced was compared in these two groups.
Results
The surgery time until entry reaming commenced was 8.9 min (range 6–12 min) using the round
sleeve and 6.2 min (range 3–12 min) using the heart-shaped sleeve (P <
0.05) (Fig. 5). The surgery time until entry
reaming commenced decreased on average by 2.7 min when using the guide-pin-first approach
with the heart-shaped sleeve. Moreover, as can be seen in the abovementioned videos and in
the video of the entire novel procedure (available at
http://www.fujita-hu.ac.jp/~fujitaqq/sdc5.mov), the technical complication has been greatly
decreased.
Case 1
A 33-year-old man was hit by a car and suffered a Gustilo type 3A tibial fracture (Fig. 6A). Debridement and external fixation was
performed immediately (Fig. 6B,C). The tibia had
suffered a multiple segmented fracture. To maintain the reduction during surgery and to
avoid perforating the posterior cortex of the proximal tibia with the nail, an Expert Tibial
Nail (Synthes) was inserted using SPA (Fig. 6D,E).
The fracture healed within 10 months, and the nail was removed 18 months after the first
operation (Fig. 6F).
Discussion
In 1996, Tornetta and Collins8 reported a
semi-extended position of the knee during an open medial parapatellar arthrotomy, a
procedure aimed at solving the problem of malalignment of tibial fracture. In 1998,
Cole9 advocated a limited medial
parapatellar arthrotomy with retraction of the patella lateral to the femoral sulcus.
Finally, in late 2007, Tornetta and Ryan10
revised the semi-extended positioning to a minimal 2.5-cm medial skin incision proximal to
the patella. This percutaneous minimally invasive intramedullary nailing technique is a
proven fixation mode for fracture stabilization in tibial shaft fractures. However, it is
much easier to pass the trocar through the PFJ in a full extended knee position, a procedure
that we perform preferentially.
Intramedullary nail insertion in the knee extended position has several clinical merits.
(1) In the classic nailing procedure, an assistant is needed to reduce the fracture and to
maintain the appropriate position until the nail has traversed the fracture site. With SPA,
reduction and the nailing procedure is easily completed, and an assistant surgeon is not
required. During nail insertion using SPA, there is no danger of posterior cortical
perforation, a complication that was occasionally seen when using the classic parapatellar
or patellar tendon-splitting approach. (2) C-arm visualization in both the AP and lateral
planes during nail insertion is mandatory to avoid further fragmentation or deformity.
However, obtaining adequate intraoperative radiographic imaging is challenging in
conventional intramedullary nailing with hip and knee in a flexed position. SPA facilitates
two-plane C-arm visualization. It avoids the need to change the position of the leg during
reduction and nail insertion. (3) In proximal tibial fracture, the knee flexion can lead to
apex anterior angulation secondary to over-pull of the quadriceps muscle. However, the
extended position of SPA relaxes the quadriceps muscle, preventing procurvatum deformity.
(4) The classic parapatellar and transtendon approaches are associated with postoperative
anterior knee pain, which is one of the most common complaints after tibial intramedullary
nailing. Court-Brown11 found the incidence
of anterior knee pain to be 56% when using the classic approach. Keating12 compared knee pain after parapatellar and
patellar tendon-splitting approaches. They found that 77% of patients developed knee pain
after a tendon-splitting incision, whereas only 50% developed pain with a parapatellar
approach. SPA has the potential to reduce the incidence of anterior knee pain. The
infrapatellar nerve is well protected and not at risk of injury when using this approach.
Additionally, soft tissue scar formation will not form on the anterior knee, but superior to
the patella, which may reduce pain on kneeling. SPA also has the advantage of allowing the
use of a patellar tendon weight-bearing brace, because the surgical scar is not located in
the anterior knee.
Despite these merits of SPA, insertion of the trocar in the PFJ is often troublesome
because the traditional round trocar is incompatible with the shape of the ridge of the
patella, meaning that the round sleeve cannot be stabilized in the appropriate position. It
is crucial to create an entry hole in the correct location in intramedullary nailing.
However, if the patella subluxates laterally (or medially), the restoring force of the
patella displaces the sleeve.
To solve this problem, we produced a heart-shaped sleeve, taking into consideration the
shape of the joint surface, the patellar facet angle (on average 130°) and the sulcus angle
(on average 140°). The tip of the sleeve is gradually tapered so as not to injure the joint
surface during insertion. As a result, the heart-shaped sleeve is easily stabilized in the
PFJ because of its specially designed shape.
Furthermore, we produced a cannulated trocar to simplify the whole procedure. In
conventional SPA, a round sleeve and trocar is inserted before inserting the guide pin. In
contrast, in our novel method, the guide pin is carefully inserted through the PFJ first
(the so-called “guide-pin-first method”). The cannulated trocar is then inserted over the
guide pin, and the heart-shaped sleeve is inserted over the trocar. This procedure is
analogous to the Seldinger technique used when inserting intravenous catheters. With our
novel heart-shaped sleeve and the guide-pin-first method, the whole procedure can be
performed simply.
The percutaneous suprapatellar technique reduces the risk of perforating the posterior
cortex of the tibia, helps to reduce varus or valgus deformities by using the femoral
trochlear groove as a guide to the entry point of the nail, and simplifies the acquisition
of intraoperative radiographs using a C-arm because there is no need to change the position
of the leg during reduction and nail insertion. Moreover, SPA is easily mastered, and has no
disadvantages compared to classic tibial nailing.13,14,15,16 Although
the invasion to the PFJ are reported minimally invasive,3,4 SPA still
has the potential to damage the PFJ.However, our heart-shaped sleeve has a better fit to the
PFJ than the ordinarily used sleeves, and therefore causes less damage to the joint
cartilage.
Although prospective randomized controlled trials are required to confirm the benefits of
the SPA technique, we are confident that SPA has many advantages. The novel heart-shaped
sleeve and the guide-pin-first method described here greatly simplify the whole SPA
procedure and are likely to provide beneficial outcomes for intramedullary nailing of tibial
shaft fractures.
Conflicts of Interest
There are no conflicts of interest to declare.
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