Tibial Nailing with the Knee Semi-Extended

Abstract

Tibial shaft fractures are the most common long bone fractures, with an incidence of approximately twenty-six per 100,000 per year1. Intramedullary nailing has become the preferred treatment for the majority of unstable diaphyseal tibial fractures. A large body of literature documents a high rate of union, acceptable alignment in all planes, and a low complication rate when diaphyseal tibial fractures are treated with intramedullary nailing2,3. Intramedullary nailing is increasingly being applied to a broader range of tibial fracture patterns, including open injuries, proximal and distal metaphyseal fractures, and fractures with intra-articular extension3-6. Historically, intramedullary nailing of the tibia has been most commonly performed with the knee in a deeply flexed (120° to 130°) position as originally described by Kuntscher in the 1940s2. Transpatellar and parapatellar approaches have been described, and these necessitate knee flexion in order to avoid injury to the patella7,8. Although intramedullary nailing of the tibia has been refined substantially over the years and has proven to be successful for a variety of fracture patterns, challenges persist. With traditional intramedullary tibial nailing performed with the knee flexed, maintenance of reduction and mitigation of deforming forces are especially difficult with fractures in the proximal one-quarter of the tibia9. Although the literature is still inconclusive, concern also remains regarding persistent knee pain after tibial nailing with the knee flexed10,11. Lastly, we believe that intramedullary nailing of the tibia with the knee flexed makes it challenging to acquire adequate intraoperative fluoroscopic imaging and to place supplemental fixation or convert to an open reduction when necessary. Semi-extended tibial nailing was initially developed by Tornetta and Collins12 for proximal-quarter tibial fractures, but it is being increasingly applied as a tool …