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Erschienen in: European Journal of Trauma and Emergency Surgery 6/2018

20.11.2017 | Original Article

Infrapatellar vs. suprapatellar approach to obtain an optimal insertion angle for intramedullary nailing of tibial fractures

verfasst von: Joerg Franke, Annika Homeier, Lars Metz, Thilo Wedel, Volker Alt, Sven Spät, Bernd Hohendorff, Reinhard Schnettler

Erschienen in: European Journal of Trauma and Emergency Surgery | Ausgabe 6/2018

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Abstract

Background

During intramedullary nailing of tibial fractures, the insertion angle of the nail is of great importance. When the nail impacts the posterior cortex due to a large insertion angle with a dorsal target course, higher insertion forces are needed, and the danger of iatrogenic fractures increases. Accordingly, the insertion direction should be as parallel as possible to the longitudinal axis of the tibia. We aimed to confirm the hypothesis that intramedullary nailing of tibial fractures can be performed with smaller insertion angles via a suprapatellar approach rather than infrapatellar approach.

Methods

In 19 human bodies of donors with intact tibiae, we performed intramedullary nailing by both a suprapatellar and an infrapatellar approach. The correct entry point was determined by fluoroscopy. Subsequently, the medullary canal was reamed up to a diameter of 10 mm, and a 9 mm polytetrafluorethylen tube was inserted instead of a tibia nail. The angle between the proximal aspect of the tube and the longitudinal axis of the tibia was measured using a computer-assisted surgery system.

Results

The angle between the proximal aspect of the inserted tube, simulating the tibial nail, and the longitudinal tibial axis was significantly larger when using the infrapatellar approach.

Conclusions

We achieved an insertion angle significantly more parallel to the longitudinal axis when using a suprapatellar approach for intramedullary nailing of tibial fractures. Thereby, both the risk of iatrogenic fracture of the posterior cortex and apex anterior angulation of the short proximal fragment can be reduced during intramedullary nailing of tibial fractures.
Literatur
1.
Zurück zum Zitat Ahlers J, von Issendorff WD. Häufigkeit und Ursachen von Fehlstellungen nach Unterschenkelmarknagelung. Unfallchirurgie. 1992;18:31–6.CrossRef Ahlers J, von Issendorff WD. Häufigkeit und Ursachen von Fehlstellungen nach Unterschenkelmarknagelung. Unfallchirurgie. 1992;18:31–6.CrossRef
2.
Zurück zum Zitat Alms M. Medullary nailing for fracture of the shaft of the tibia. J B Jt Surg Br. 1962;44:328–39.CrossRef Alms M. Medullary nailing for fracture of the shaft of the tibia. J B Jt Surg Br. 1962;44:328–39.CrossRef
3.
Zurück zum Zitat Attal R, Hansen M, Kirjavainen M, Bail H, Hammer O, Rosenberger R, et al. A multicenter case series of tibia fractures treated with the Expert Tibia Nail (ETN). Arch Orthop Trauma Surg. 2012;132:975–84.CrossRef Attal R, Hansen M, Kirjavainen M, Bail H, Hammer O, Rosenberger R, et al. A multicenter case series of tibia fractures treated with the Expert Tibia Nail (ETN). Arch Orthop Trauma Surg. 2012;132:975–84.CrossRef
4.
Zurück zum Zitat Beltran MJ, Collinge CA, Patzkowski JC, Masini BD, Blease RE, Hsu JR. Intraarticular risks of suprapatellar nailing. Am J Orthop. 2012;41:546–50.PubMed Beltran MJ, Collinge CA, Patzkowski JC, Masini BD, Blease RE, Hsu JR. Intraarticular risks of suprapatellar nailing. Am J Orthop. 2012;41:546–50.PubMed
5.
Zurück zum Zitat Bhandari M, Audige L, Ellis T, Hanson B. Evidence-Based Orthopaedic Trauma Working Group. Operative treatment of extra-articular proximal tibial fractures. J Orthop Trauma. 2003;17:591–5.CrossRef Bhandari M, Audige L, Ellis T, Hanson B. Evidence-Based Orthopaedic Trauma Working Group. Operative treatment of extra-articular proximal tibial fractures. J Orthop Trauma. 2003;17:591–5.CrossRef
6.
Zurück zum Zitat Bono CM, Levine RG, Rao JP, Behrens FF. Nonarticular proximal tibia fractures: treatment options and decision making. J Am Acad Orthop Surg. 2001;9:176–86.CrossRef Bono CM, Levine RG, Rao JP, Behrens FF. Nonarticular proximal tibia fractures: treatment options and decision making. J Am Acad Orthop Surg. 2001;9:176–86.CrossRef
7.
Zurück zum Zitat Buehler KC, Green J, Woll TS, Duwelius PJ. A technique for intramedullary nailing of proximal third tibia fractures. J Orthop Trauma. 1997;11:218–23.CrossRef Buehler KC, Green J, Woll TS, Duwelius PJ. A technique for intramedullary nailing of proximal third tibia fractures. J Orthop Trauma. 1997;11:218–23.CrossRef
8.
Zurück zum Zitat Carr JB, Sobba DB, Bear LL. Biomechanics of rigid tibial nail insertion sites. Am J Orthop. 1996;25:553–6.PubMed Carr JB, Sobba DB, Bear LL. Biomechanics of rigid tibial nail insertion sites. Am J Orthop. 1996;25:553–6.PubMed
9.
Zurück zum Zitat Chan DS, Serrano-Riera R, Griffing R, Steverson B, Infante A, Watson D, et al. Suprapatellar versus infrapatellar tibial nail insertion: a prospective randomized control pilot study. J Orthop Trauma. 2016;30:130–4.CrossRef Chan DS, Serrano-Riera R, Griffing R, Steverson B, Infante A, Watson D, et al. Suprapatellar versus infrapatellar tibial nail insertion: a prospective randomized control pilot study. J Orthop Trauma. 2016;30:130–4.CrossRef
10.
Zurück zum Zitat Cole JD. Intramedullary fixation of proximal tibia fractures. Tech Orthop. 1998;13:27–37.CrossRef Cole JD. Intramedullary fixation of proximal tibia fractures. Tech Orthop. 1998;13:27–37.CrossRef
11.
Zurück zum Zitat Court-Brown CM. Reamed intramedullary tibial nailing: an overview and analysis of 1106 cases. J Orthop Trauma. 2004;18:96–101.CrossRef Court-Brown CM. Reamed intramedullary tibial nailing: an overview and analysis of 1106 cases. J Orthop Trauma. 2004;18:96–101.CrossRef
12.
Zurück zum Zitat Eastman JG, Tseng SS, Lee MA, Yoo BJ. The retropatellar portal as an alternative site for tibial nail insertion: a cadaveric study. J Orthop Trauma. 2010;24:659–64.CrossRef Eastman JG, Tseng SS, Lee MA, Yoo BJ. The retropatellar portal as an alternative site for tibial nail insertion: a cadaveric study. J Orthop Trauma. 2010;24:659–64.CrossRef
13.
Zurück zum Zitat Eastman JG, Tseng SS, Lo E, Li CS, Yoo B, Lee M. Retropatellar technique for intramedullary nailing of proximal tibia fractures: a cadaveric assessment. J Orthop Trauma. 2010;24:672–6.CrossRef Eastman JG, Tseng SS, Lo E, Li CS, Yoo B, Lee M. Retropatellar technique for intramedullary nailing of proximal tibia fractures: a cadaveric assessment. J Orthop Trauma. 2010;24:672–6.CrossRef
14.
Zurück zum Zitat Franke J, Hohendorff B, Alt V, Thormann U, Schnettler R. Suprapatellar nailing of tibial fractures-Indications and technique. Injury. 2016;47:495–501.CrossRef Franke J, Hohendorff B, Alt V, Thormann U, Schnettler R. Suprapatellar nailing of tibial fractures-Indications and technique. Injury. 2016;47:495–501.CrossRef
15.
Zurück zum Zitat Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res. 1995;315:25–33. Freedman EL, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop Relat Res. 1995;315:25–33.
16.
Zurück zum Zitat Freeman AL, Craig MR, Schmidt AH. Biomechanical comparison of tibial nail stability in a proximal third fracture: do screw quantity and locked, interlocking screws make a difference? J Orthop Trauma. 2011;25:333–9.CrossRef Freeman AL, Craig MR, Schmidt AH. Biomechanical comparison of tibial nail stability in a proximal third fracture: do screw quantity and locked, interlocking screws make a difference? J Orthop Trauma. 2011;25:333–9.CrossRef
17.
Zurück zum Zitat Gelbke MK, Coombs D, Powell S, DiPasquale TG. Suprapatellar versus infra-patellar intramedullary nail insertion of the tibia: a cadaveric model for comparison of patellofemoral contact pressures and forces. J Orthop Trauma. 2010;24:665–71.CrossRef Gelbke MK, Coombs D, Powell S, DiPasquale TG. Suprapatellar versus infra-patellar intramedullary nail insertion of the tibia: a cadaveric model for comparison of patellofemoral contact pressures and forces. J Orthop Trauma. 2010;24:665–71.CrossRef
18.
Zurück zum Zitat Hernigou P, Cohen D. Proximal entry for intramedullary nailing of the tibia. The risk of unrecognized articular damage. J B Jt Surg Br. 2000;82:33–41.CrossRef Hernigou P, Cohen D. Proximal entry for intramedullary nailing of the tibia. The risk of unrecognized articular damage. J B Jt Surg Br. 2000;82:33–41.CrossRef
19.
Zurück zum Zitat Hiesterman TG, Shafiq BX, Cole PA. Intramedullary nailing of extra-articular proximal tibia fractures. J Am Acad Orthop Surg. 2011;19:690–700.CrossRef Hiesterman TG, Shafiq BX, Cole PA. Intramedullary nailing of extra-articular proximal tibia fractures. J Am Acad Orthop Surg. 2011;19:690–700.CrossRef
20.
Zurück zum Zitat Jones M, Parry M, Whitehouse M, Mitchell S. Radiologic outcome and patient-reported function after intramedullary nailing: a comparison of the retro- patellar and infrapatellar approach. J Orthop Trauma. 2014;28:256–62.CrossRef Jones M, Parry M, Whitehouse M, Mitchell S. Radiologic outcome and patient-reported function after intramedullary nailing: a comparison of the retro- patellar and infrapatellar approach. J Orthop Trauma. 2014;28:256–62.CrossRef
21.
Zurück zum Zitat Lang GJ, Cohen BE, Bosse MJ, Kellam JF. Proximal third tibial shaft fractures. Should they be nailed? Clin Orthop Relat Res. 1995;315:64–74. Lang GJ, Cohen BE, Bosse MJ, Kellam JF. Proximal third tibial shaft fractures. Should they be nailed? Clin Orthop Relat Res. 1995;315:64–74.
22.
Zurück zum Zitat Lottes JO. Medullary nailing of the tibia with the triflange nail. Clin Orthop Relat Res. 1974;105:53–66.CrossRef Lottes JO. Medullary nailing of the tibia with the triflange nail. Clin Orthop Relat Res. 1974;105:53–66.CrossRef
23.
Zurück zum Zitat Liporace FA, Stadler CM, Yoon RS. Problems, tricks, and pearls in intrame-dullary nailing of proximal third tibial fractures. J Orthop Trauma. 2013;27:56–62.CrossRef Liporace FA, Stadler CM, Yoon RS. Problems, tricks, and pearls in intrame-dullary nailing of proximal third tibial fractures. J Orthop Trauma. 2013;27:56–62.CrossRef
24.
Zurück zum Zitat McConnell T, Tornetta P III, Tilzey J, Casey D. Tibial portal placement: The radiographic correlate of the anatomic safe zone. J Orthop Trauma. 2001;15:207–9.CrossRef McConnell T, Tornetta P III, Tilzey J, Casey D. Tibial portal placement: The radiographic correlate of the anatomic safe zone. J Orthop Trauma. 2001;15:207–9.CrossRef
25.
Zurück zum Zitat Nork SE, Barei DP, Schildhauer TA, Agel J, Holt SK, Schrick JL, et al. Intrame-dullary nailing of proximal quarter tibial fractures. J Orthop Trauma. 2006;20:523–8.CrossRef Nork SE, Barei DP, Schildhauer TA, Agel J, Holt SK, Schrick JL, et al. Intrame-dullary nailing of proximal quarter tibial fractures. J Orthop Trauma. 2006;20:523–8.CrossRef
26.
Zurück zum Zitat Pfister U, Frigg R. Locking of the intramedullary nail in the medullary cavity of the tibia. Aktuelle Traumatol. 1980;10:117–21.PubMed Pfister U, Frigg R. Locking of the intramedullary nail in the medullary cavity of the tibia. Aktuelle Traumatol. 1980;10:117–21.PubMed
27.
Zurück zum Zitat Ricci WM, O’Boyle M, Borrelli J, Bellabarba C, Sanders R. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma. 2001;15:264–70.CrossRef Ricci WM, O’Boyle M, Borrelli J, Bellabarba C, Sanders R. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma. 2001;15:264–70.CrossRef
28.
Zurück zum Zitat Samuelson MA, McPherson EJ, Norris L. Anatomic assessment of the proper insertion site for a tibial intramedullary nail. J Orthop Trauma. 2002;16:23–5.CrossRef Samuelson MA, McPherson EJ, Norris L. Anatomic assessment of the proper insertion site for a tibial intramedullary nail. J Orthop Trauma. 2002;16:23–5.CrossRef
29.
Zurück zum Zitat Sanders RW, DiPasquale TG, Jordan CJ, Arrington JA, Sagi HC. Semiextended intramedullary nailing of the tibia using a suprapatellar approach: radiographic results and clinical outcomes at a minimum of 12 month follow-up. J Orthop Trauma. 2014;28:S29–39.CrossRef Sanders RW, DiPasquale TG, Jordan CJ, Arrington JA, Sagi HC. Semiextended intramedullary nailing of the tibia using a suprapatellar approach: radiographic results and clinical outcomes at a minimum of 12 month follow-up. J Orthop Trauma. 2014;28:S29–39.CrossRef
30.
Zurück zum Zitat Schröder M, Gottschling H, Reimers N, Hauschild M, Burgkart R. Automated morphometric analysis of the femur on large anatomical databases with highly accurate correspondence detection. Open Med J. 2014;1:15–22.CrossRef Schröder M, Gottschling H, Reimers N, Hauschild M, Burgkart R. Automated morphometric analysis of the femur on large anatomical databases with highly accurate correspondence detection. Open Med J. 2014;1:15–22.CrossRef
31.
Zurück zum Zitat Stinner DJ, Mir H. Techniques for intramedullary nailing of proximal tibia fractures. Orthop Clin N Am. 2014;45:33–45.CrossRef Stinner DJ, Mir H. Techniques for intramedullary nailing of proximal tibia fractures. Orthop Clin N Am. 2014;45:33–45.CrossRef
32.
Zurück zum Zitat Sun Q, Nie XY, Gong JP, Wu JZ, Li RL, Ge W, et al. The outcome comparison of the suprapatellar approach and infrapatellar approach for tibia intramedullary nailing. Int Orthop. 2016;40:2611–17.CrossRef Sun Q, Nie XY, Gong JP, Wu JZ, Li RL, Ge W, et al. The outcome comparison of the suprapatellar approach and infrapatellar approach for tibia intramedullary nailing. Int Orthop. 2016;40:2611–17.CrossRef
33.
Zurück zum Zitat Tornetta P, Collins E. Semiextended position of intramedullary nailing of the proximal tibia. Clin Orthop Relat Res. 1996;328:185–9.CrossRef Tornetta P, Collins E. Semiextended position of intramedullary nailing of the proximal tibia. Clin Orthop Relat Res. 1996;328:185–9.CrossRef
34.
Zurück zum Zitat Tornetta P, Riina J, Geller J, Purban W. Intraarticular anatomic risks of tibial nailing. J Orthop Trauma. 1999;13:247–51.CrossRef Tornetta P, Riina J, Geller J, Purban W. Intraarticular anatomic risks of tibial nailing. J Orthop Trauma. 1999;13:247–51.CrossRef
35.
Zurück zum Zitat Tytherleigh-Strong GM, Keating JF, Court-Brown CM. Extra-articular fractures of the proximal tibia diaphysis: their epidemiology, management and out-come. J R Coll Surg Edinb. 1997;42:334–8.PubMed Tytherleigh-Strong GM, Keating JF, Court-Brown CM. Extra-articular fractures of the proximal tibia diaphysis: their epidemiology, management and out-come. J R Coll Surg Edinb. 1997;42:334–8.PubMed
36.
Zurück zum Zitat Yasuda T, Obara S, Hayashi J, Arai M, Sato K. Semiextended approach for intramedullary nailing via a patellar eversion technique for tibial-shaft fractures: evaluation of the patellofemoral joint. Injury. 2017;48:1264–8.CrossRef Yasuda T, Obara S, Hayashi J, Arai M, Sato K. Semiextended approach for intramedullary nailing via a patellar eversion technique for tibial-shaft fractures: evaluation of the patellofemoral joint. Injury. 2017;48:1264–8.CrossRef
37.
Zurück zum Zitat Yoo JH, Chang CB, Shin KS, Seong SC, Kim TK. Anatomical references to assess the posterior slope in total knee arthroplasty: a comparison of 5 anatomical axes. J Arthroplast. 2008;23:586–92.CrossRef Yoo JH, Chang CB, Shin KS, Seong SC, Kim TK. Anatomical references to assess the posterior slope in total knee arthroplasty: a comparison of 5 anatomical axes. J Arthroplast. 2008;23:586–92.CrossRef
38.
Zurück zum Zitat Zamora R, Wright C, Short A, Seligson D. Comparison between suprapatellar and parapatellar approaches for intramedullary nailing of the tibia. Cadaveric study. Injury. 2016;47:2087–90.CrossRef Zamora R, Wright C, Short A, Seligson D. Comparison between suprapatellar and parapatellar approaches for intramedullary nailing of the tibia. Cadaveric study. Injury. 2016;47:2087–90.CrossRef
Metadaten
Titel
Infrapatellar vs. suprapatellar approach to obtain an optimal insertion angle for intramedullary nailing of tibial fractures
verfasst von
Joerg Franke
Annika Homeier
Lars Metz
Thilo Wedel
Volker Alt
Sven Spät
Bernd Hohendorff
Reinhard Schnettler
Publikationsdatum
20.11.2017
Verlag
Springer Berlin Heidelberg
Erschienen in
European Journal of Trauma and Emergency Surgery / Ausgabe 6/2018
Print ISSN: 1863-9933
Elektronische ISSN: 1863-9941
DOI
https://doi.org/10.1007/s00068-017-0881-8

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