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Tibnail
1.
2. AP and lateral x-rays at the level of a tibial
shaft fracture in a morbidly obese patient.
3. After appropriate x-rays are taken that demonstrate the knee
and ankle have no extension of the injuries, tibial nailing may
be performed on appropriate candidates.
4. The perfect starting portal on the AP radiograph
is located just medial to the lateral tibial eminence.
5. Depending on the anatomy of the particular patient the incision may
be either medial or lateral tot he patellar tendon. To determine the
location of the incision, a guidewire is placed on the skin and under
fluoroscopy the perfect starting portal and its direction down the tibial
shaft is identified.
7. The incision is made over the edge of the patellar tendon on
the side of the tendon that is most in line with the portal as
marked.
8. The incision should be immediately inferior to the patella
and is just long enough to allow for nail insertion
(12mm in this case).
9. The incision is brought through skin and subcutaneous tissue
and a full thickness subcutaneous flap is developed through
the incision using a Metzenbaum scissors or clamp.
10. Dissection should be limited to the paratendinous
region and not directly over the tendon.
11. It is helpful to bend the Bovi tip to enable easy
working through the incision for release of the
paratendinous fascia.
12. Using pickups or skin retractor the skin is moved from proximal
to distal, allowing a paratendinous incision (either medial or
lateral, depending on the incision) to the patellar tendon from the
level of the patella to down to just shy of the tibial surface.
13. The awl is placed through the paratendinous incision, onto
the proximal tibia. The portal position is confirmed on the AP
and lateral radiographs.
14. Just medial to the lateral
tibial emminence
Immediately anterior to
the articular surface
15. The knee is then hyperflexed and the surgeon places his or her
fingers on the tibial crest and aims the awl in that direction. This
will assure placement within a central portion of the canal.
16. If reaming is to be performed, the ball-tip guidewire is
introduced down the tibia through the incision with the
knee in full flexion.
17.
18. The guidewire is placed across the fracture site. After appropriate
reaming, the nail length determined.
19. Length may be determined either by measuring
from the guidewire or by a radiographic ruler.
20. As with all nailing procedures, the accuracy of the
locking jig should be confirmed before nail placement
21. The nail is gently advanced using a slap hammer until it is
almost seated. At that point, radiographs are taken at the
level of the ankle and knee to confirm that there is enough
room to fully seat the nail.
22. If the radiographs demonstrate that the nail is the appropriate length, it is
tapped into its templated position distally. A lateral radiograph of the knee
taken to confirm that the nail is seated underneath subchondral bone.
23.
24. The nail is then locked proximally through the jig. Distal locking
is performed freehand using a perfect circle technique.
25. This entails holding the leg in a neutral position,
allowing a perfect lateral radiograph of the hole to be
taken (the hole must appear to be a perfect circle)
26. A sharp awl is then placed through a small incision
into the center of the perfect circle.
27. Once the awl is in the center of the perfect circle, it is
oriented in the plane of the C-arm and divot in the bone
is made by tapping on the awl. This divot allows for
easier drilling of the hole.
28. After screw placement, their length is confrimed on the AP radiograph
and the position through the nail in the lateral (blackout) radiograph.
