Interlocking nailing

The interlocking nails have now become an established method of internal fixation. The introduction of better nail designs, innovations in the interlocking techniques and universal availability of image intensifiers have contributed a great deal to the evolution and widespread applications of this technique. It is truly said, that from difficulties arises the zeal to evolve, and from the zeal arises the new adaptations. My experience with the interlocking nails has been more than a decade long story of experiments with this art.

Nailing

Diep The Hoa MD - HTO

DD Tanna MS (Ortho)Honorary ConsultantJaslok HospitalBhatia HospitalSaifee HospitalMumbai, Maharashtra, IndiaConsultant Orthopedic Surgeon

Backbay View3A Mama Parmamand MargMumbai, Maharashtra, India

• Ahmedabad, Phone: Rel: +91-79-32988717, e-mail: ahmedabad@jaypeebrothers.com

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This book has been published in good faith that the material provided by author is original Every effort is made to ensure acc uracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error (s) In case of any disp ute, all legal matters are to be settled under Delhi jurisdiction only.

Dedicated to

Dr KV Chaubal, a retired Professor of OrthopedicsBYL Nair Hospital and TN Medical CollegeMumbai, Maharashtra, India

I have worked with Dr Chaubal, as a Resident, as a Lecturer, as an Assistant Honorary and finally as hiscolleague at the BYL Nair Hospital I continued to associate with him at the Bhatia Hospital, till recently Now

he has retired from orthopedics recently, and spends his time at home and family

This book is dedicated

to him not for the post he held in our institution

It is the tribute to a person who has the most remarkable approach to teaching According to him, learning

is not just gathering information and storing it He made tireless efforts to teach all his students to thinkindependently He inspired and encouraged all of us to rise to our highest potential He broke the old traditionthat the master should be obeyed blindly He strongly believes that learning is not at the feet of master, but byarguing and discussing with him In this way, the master and the disciple both learn This is the most importantlesson to be learnt today, not only in orthopedics, but also in every field of life

It is the matter of great privilege and honor for me to have been associated with Dr Chaubal during myentire career in orthopedics

I am never tired of interacting with him even now after all these years Now he has retired from orthopedicpractise I feel the vacuum in my interactions, as now I meet him very infrequently

Diep The Hoa MD - HTO

Preface to the Third Edition

When I was asked to do 3rd edition of my book, initially I felt, there is not much changed in interlocking in last

5 years so what is the purpose of 3rd edition But when I started modifying 2nd edition, I realized how lockingplate has become a big replacement for interlocking nail, and in many situations it has replaced the nailingprocedure Keeping this in mind, I have introduced the Chapter on Locking Plates I have also describedwherever it is alternative treatment to nailing to me I felt treating surgeon will have a ready-reference oflocking plate also in the given fracture Many new case studies and new bold changes of concept have beenincluded I also requested Dr B Shiv Shankar, Sholapur to write on his nail extraction device which he hassuccessfully introduced I also requested Dr Sunil Kulkarni, Miraj to write on antibiotic coated nail for infectedsurgery and how to make these nails I felt these two new introductions will help readers to have completeknowledge of the art I am very thankful to Dr B Shiv Shankar and Dr Sunil Kulkarni for their ready acceptance

to write in this book I thank my associate Dr Gauresh Palekar for his help and Dr Anand Thakur to lend meplenty of hand-drawings from his book

DD Tanna ddtanna@gmail.com

Diep The Hoa MD - HTO

Preface to the Second Edition

The interlocking nails have now become an established method of internal fixation The introduction of betternail designs, innovations in the interlocking techniques and universal availability of image intensifiers havecontributed a great deal to the evolution and widespread applications of this technique

It is truly said, that from difficulties arises the zeal to evolve, and from the zeal arises the new adaptations

My experience with the interlocking nails has been more than a decade long story of experiments withthis art

I remember those years of late eighties, when

interlocking nails had almost become a norm in the

Western world I used to hear about them in every

meeting and conference I attended abroad However,

its application was not possible back home, due to

lack of availability of the interlocking nails and the

image intensifiers I began to use interlocking nails

somewhere in around 1992 My carpenter made the

first interlocking nail I used (Figs 1 and 2) He made

two holes proximally and distally in an ordinary

K-nail used in femur Later on, I started using custom

made nails manufactured specially for me by a

com-pany without any other instruments (Figs 3 to 6) I

used to ask them to make two nails of identical size

and with identical placement of holes (Fig 7) We used

to carry out the procedure with X-rays, as the image

intensifier had not become available at that time The success with these experiments inspired me to developthe concept of interlocking nails without the use of image intensifier With the help of the Instrument Company,

I developed a nail, which has some standardization and can be used by every surgeon Today, with increasing

Fig 2: First patient with compound comminuted tibia operated

with such nail

Fig 1: Holes were made in old K-nail femur

Fig 3: Early nail

Diep The Hoa MD - HTO

x Interlocking Nailing

Fig 4: Early instruments (Introducer along with holding handles) Fig 5: Early instruments

Fig 6: Early instruments for nail removal (Extractor was needed) Fig 7: Second identical nail was the instrument for distal jig

experience, the accuracy of interlocking with radiographs is 100 percent I published an article in JBJS in 1994

on interlocking without C-arm

I have been organizing the workshops on interlocking nails since 1994 all over India, so that more andmore surgeons can practice this art within their limited set-up However, it is not possible to reach out to awider audience by conferences and workshops This book is an effort to reach out to every possible surgeon,who wants to learn this art This book is the crux of all that I have been talking about and practicing since somany years It is not the review of literature but contains most what is published and is currently practised art

of interlocking I have emphasized what I strongly believe in and what I practice, in interlocking nailing

In this book, I have tried to cover all the aspects related to interlocking nailing I have covered each andevery step of the nailing and the interlocking procedure I have discussed, about the different techniques ofinterlocking The possible difficulties that one may come across and the practical solutions are also discussed

I have also discussed at length about my method of interlocking

I hope the reader finds this book a very helpful guide and answers many of the unanswered questions Inthis 2nd edition, I have put in lot of new experiences There are additions of chapters on ‘what we did not teachyou in workshops’ and ‘Photo Gallery.’ There is intended repetition in the book in order to make rapid readingmost fruitful

DD Tanna

Diep The Hoa MD - HTO

Preface to the First Edition

The interlocking nails have now become an established method of internal fixation The introduction of betternail designs, innovations in the interlocking techniques and the availability of image intensifiershave contributed a great deal to the evolution and widespread applications of this technique

As is said truly that from difficulties arise the zeal to evolve and from the zeal arises the discovery Myexperience with the interlocking nails has been a decade long story of experiments with this art

I remember those early years of nineties, when interlocking nails had almost become a norm in the Westernworld I used to hear about them in every meeting and conference I attended abroad However, its applicationwas not possible in India due to lack of availability of the interlocking nails and the image intensifiers Ibegan to use interlocking nails somewhere in around 1992 The first interlocking nail I used was made by

my carpenter He made two holes proximally and distally in an ordinary K-nail used in femur Later on,

I started using custom-made nails manufactured specially for me by a company I used to ask them to maketwo nails of identical size and with identical placement of holes We used to carry out the procedure withradiographs, as the image intensifier had not become available at that time The success with these experimentsinspired me to develop the concept of interlocking nails without the use of image intensifier With the help

of the instrument company, I developed a nail, which has some standardization and can be used by everysurgeon Today, with increasing experience, the accuracy of interlocking with radiographs is 100 percent

I have been organizing the workshops on interlocking nails since 1994 all over India, so that more andmore surgeons can practise this art within their limited set-up However, it is not possible to reach out to

a wider audience merely by conferences and workshops This book is an effort to reach out to every possiblesurgeon, who wants to learn this art This book is the crux of all that I have been talking about and practisingsince so many years It is not the review of literature I have emphasized what I strongly believe in and what

I practise, in interlocking nailing

In this book, I have tried to cover all the aspects related to interlocking nailing I have covered each andevery step of the nailing and the interlocking procedure I have discussed about the different techniques ofinterlocking The possible difficulties that one may come across and the practical solutions are also discussed

I have also discussed at length about my method of interlocking In the last chapter, I have covered the recentdevelopments like Recon nail, Polarus nail, Gamma nail There is a brief mention of the various otherapplications of the interlocking nails also

I hope the reader will find this book a very helpful guide and get answers of many unanswered questions

DD Tanna

Diep The Hoa MD - HTO

1 Introduction to Interlocking Nailing 1

2 Interlocking Tibia Nail 3

3 Lower One-third Fracture of the Tibia 17

4 Upper One-third and One-fourth Fractures 26

5 Locked Nails of the Femur 32

6 Tips on Tibia and Femur 40

7 Open Fractures 44

8 Reaming 49

9 Nonunion 55

10 Complications Associated with Procedure of Nailing and Locking and Implant Removal 60

11 Fracture Neck Femur with Shaft Femur 75

12 Dynamization 78

13 Fractures of Proximal Femur 83

14 Supracondylar Nail 95

15 Fracture Humerus Interlocking Nail 108

16 Extended Use of Interlocking Nails 125

17 New Developments and Perspectives 133

18 What We did not Teach in Workshops? 135

19 Locking Plates 144

Photo Gallery 157

Suggested Reading 191

Index 197 Diep The Hoa MD - HTO

It is recorded that the Aztecs used wooden intramedullary nails 500 years ago Early orthopedic surgeonssuch as Senn, Lambotte and Heygroves investigated the use of ivory, bone and metallic nails Theintramedullary techniques that are in common use today are derived mainly from Gerhard Kuntscher, theFather of Reamed Intramedullary Nailing in Germany, and the Rush family in the USA Herzog usedKuntscher’s femoral nail for nonunion and delayed union

Since Kuntscher’s time, the nail has been modified to incorporate the natural anterior bow of the femur,although the overall shape of the tibial nail has remained essentially unchanged

Initially, Kuntscher introduced the interlocking nail, which was later modified by Huckstep, Klemn,Grosse, Kempf and others Most current designs permit two cross-screws distal to the fracture with one,two or three cross-screws proximal to the fracture

BIOMECHANICS

Interlocking nails act as internal splints, serving as load-sharing devices, stabilizing fracture fragments, andmaintaining alignment while permitting slight bending during functional activities, a thicker nail may notallow bending By allowing the movement of adjacent joints, rehabilitation is concurrent with treatmentand stress-shielding is minimal

Nails have been tested on human cadavers with respect to the strength of whole bone in static bendingand torsion The Kuntscher type nail with open section design provided bending strength and stiffnessequal to or greater than comparable solid designs However, torsion rigidity was lower for the open sectionnails compared to solid nails

BIOLOGY

The long bones of adults receive their blood supply from a three-vessel system — the nutrient, the metaphyseal,and the periosteal vessels The nutrient artery is responsible for the perfusion of the marrow and the innertwo-thirds or three-quarters of the diaphyseal cortex The periosteal supply the outer parts of the cortex butthere is some overlap in the nutritional responsibilities of both systems Metaphyseal vessels provide numerousanastamoses with the branches of the nutrient artery

The controversy regarding the contribution of the medullary blood supply versus the periosteal bloodsupply to the cortex is still unsettled In many instances, the trauma that produced the fracture of the longbone is itself sufficient to disrupt medullary as well as periosteal blood flow It also, damages the surroundingsoft tissues The design of most nails is such that the space around the nail is available for reconstruction of

2 Interlocking Nailing

the medullary blood network although much of the healing of the fracture is through the peripheral bloodsupply

Fracture fixed with intramedullary nails displayed higher values for blood flow in the whole bone and

at the fracture site, which remained elevated for a longer time than those managed with rigid plate fixation.These findings correlate with increased peripheral callus in the patients treated with intramedullary nailing

FRACTURE HEALING FOLLOWING INTRAMEDULLARY NAILING

The peripheral circulation is generally maintained However, the reaming process causes additional damage

In interlocking nail, it has been observed that small vessels grow into the existing gaps between the boneand the nail in an astonishingly short period of time, from where they penetrate into the neighboring malperfused cortical bone and initiate endosteal bone formation It is postulated that even the bone dust producedafter reaming may have osteoinductive properties, causing endosteal callus formation

Snugly fitting Nail, gives the best results The healing of a well-done closed nailing of the shaft of thetibia or the femur depends on the fracture geometry and the level of the fracture Healing is a biologicalprocess controlled by mechanical stability I think both play an important part

Diep The Hoa MD - HTO

2 Int Interloc erloc erlocking Tibia Nail king Tibia Nail

Interlocking nail is with at least two proximal holes and two distal holes Locking bolts or screw passthrough these holes and stabilizes the fracture Rotation and collapse is controlled with locking at bothends Recently, nails have been devised with proximal locking screws, in different directions likeanteroposterior, lateral and oblique directions, to improve the stability obtained after locking nail Specialjig has developed for putting these screws perfectly; also there are oblong holes at either or both ends to putscrew in dynamic mode This screw will not allow rotation movements but will allow impaction of thefracture on walking, as the screw can glide down in the hole and hence there is no need for dynamization ofthe nail Distal ends also has provision for 2-3 screws put free hand at 90° to each other improving the

stability (Fig 2.1).

DESIGN OF TIBIA NAILS

Grosse and Kempf Nail from Strasburg has popularized interlocking nailing Later AO modified the designwith change of Herzog band But all the later manufactures have devised their nails on GK design with

minor modification (Figure 2.2) Even AO has now option of Herzog band proximally in their newer nails.

For all practical purpose original AO nail with distal Herzog band is now not used

Fig 2.1: Distal end can take 3 screws in different directions

Fig 2.2: AO design with Herzog band distally, GK with

Herzog band proximally Diep The Hoa MD - HTO

4 Interlocking Nailing

There are two nails, which have tried to avoid difficult

distal locking exercises

One of them is the expandable (Viagra) nail Smaller

diameter nail is introduced in medullary cavity After sitting

in the medullary canal, it will expand to predetermined

thicker size hugging the medullary cavity on saline injection

in the nail This expansion will immobilize the fracture and

difficult distal locking is avoided (Figs 2.3 and 2.4) It is

observed that differential expansion occurs depending on

the width of the medullary cavity due to its peculiar design

and that gives it a bigger use It has one limitation it will not

expand at the end of the nails and it has to be used for isthmus

fractures only I have used it and it is very functional and

could become popular over the time, if more surgeons try it

Second nail introduced is the flanged nail This

modification has been introduced in the Brooker Wills, Derby,

and Medinov nails It is a curved nail with a cloverleaf cross-section and a

metal insert bearing two sharp flanges distally After introducing the nail, the

flanges are opened to hold the cortices of the distal fragment (Fig 2.5) The

proximal screw is then passed to maintain the flanges open by pressing down

on the central metal rod that lies between the proximal screw and the distal

flanges This nail does away with the problem of distal screw insertion

Occasionally, flanges penetrate in the bone It may be difficult to retract the

flanges prior to nail extraction At present, the AO or GK and their variations

are extensively used (Fig 2.6) Different human are of different size and

length, around the world with many ethnic differences

With the growth in popularity of interlocking nails, the number of available

designs has increased It has been difficult to substantiate the clinical

advantage of one design over the other Stainless steel and titanium nails

appear to give equal results Nails with a closed section (circular nails) and Fig 2.5: Flange type of distal locking

Fig 2.3: Expandable nail

Figs 2.4A and B: (A) Expandable nail (B) Small incision percutaneuos nailing

B A

Diep The Hoa MD - HTO

Interlocking Tibia Nail

those with an open section (slotted nails) also provide similar results Closed-section nails offer increasedtorsional rigidity, but this property has no clinical significance and may lead to increased comminution atthe fracture site

Wall thickness has been studied in detail, and attempts have been made to increase the strength andaugment the fatigue resistance of the nail However, there is little evidence that these differences translateinto a higher clinical success rate

The only important factor related to nail design is that more rigid nails require further over reaming

INDICATIONS FOR INTERLOCKING NAILING

They include the following:

1 All closed fractures of the tibia except those at the ends of the bone

2 Aseptic nonunion

3 Pathological fractures

4 Malunion

5 Deformity Correction

6 Septic nonunion in two stages

7 Open fractures up to the grade IIIB tibia diaphyseal fractures

8 Limb-lengthening procedures

9 Arthrodesis

The ideal zone for interlocking nailing is as shown in (Figures 2.7A and B) in the middle zones.

Open fractures, treated by external fixator, resulted in delayed union and frequent pin tract infections.The fixator needs to be changed to more definite treatment like plaster or interlocking nail once the woundhas stabilized Today, most centers have reported excellent results with primary interlocking nailing ofcompound fractures up to grade IIIB, after debridement and wound care In some series, even grade IIICopen fractures have shown better results with primary intramedullary nailing than primary fixator and thennailing

Fig 2.6: Normal anatomic variation in tibia Figs 2.7A and B: The ideal zones for interlock nails in tibia and femur

Diep The Hoa MD - HTO

6 Interlocking Nailing

PREOPERATIVE ASSESSMENT FOR INTERLOCKING NAIL

The various considerations include:

Site of Fracture

Tibia fractures near the ends of the bone are not suitable for intramedullary nailing, particularly if thefracture has an intra-articular extension

Bone

Size of the Medullary Canal

The presence of an excessively narrow medullary canal is a contraindication for intramedullary nailing

Bone Quality

Intramedullary nailing was a suitable technique for osteoporotic bones where plating and external skeletalfixation are less appropriate because of the problems of maintaining screw position Now with availability

of locking plates, plating is an attractive option compared to nailing which may not give adequate stability,

if porosis has given expanded medullary cavity Today locking plates has almost replaced nail in suchseverely porotic fractures

CLOSED NAILING OF THE TIBIA

This is conventionally done with an appropriate operating table and C-arm, which allow traction and closedreduction of fracture These tables are now available all over The use of the C-arm is very helpful in closedreduction The new type of AO distracter is useful for closed nailing, but it is not as easy to use as claimed

PROCEDURE

Position of the Patient

On the special table, the patient is positioned supine, a Calcaneal pin is passed, and the knee is placed in 90°

of flexion Some surgeons use a supine position on an ordinary table I personally prefer to use an ordinarytable with the knee hanging down end or side of the table The procedure below is described for standard

position with Calcaneal traction on fracture table, First and then on ordinary table (Fig 2.8).

Fig 2.8: The position of the patient on the fracture table for interlock nailing tibia Diep The Hoa MD - HTO

Interlocking Tibia Nail

Fracture Reduction

The fracture is reduced by traction through the

Calcaneal pin and confirmed on C-arm The Calcaneal

pin should be put parallel to the ankle axis to avoid

varus or valgus malalignment The pin is tied to the

table with the specially provided stirrup, so that

traction can be adjusted while operating Apply

traction on footpiece and reduce fracture manually

and keep traction slightly in distraction, as this helps

reduction and passing of guidewires and reamers

Confirm on C-arm the position of reduction and then

proceed to pass the guidewire

Surgery on Ordinary Table

The patient lies supine at the edge of the table, so that the leg hangs free at a 90° flexion (Fig 2.9) or he can

lie on the table with straight knee and it is pulled out of table on the side and knee is kept hanging on side

of the table (Fig 2.10) Or knee is bent at 90° and hip is externally rotated and entry to the medullary cavity

is obtained (Fig 2.11) At times while passing the nail, this 90° flexion is not enough and the knee may have

to be bent more than 100°

This is the position I use routinely

Fig 2.9: Patient on edge of table, leg is hanging

Fig 2.10: Patient by side of table Fig 2.11: Normal supine position and knee bent to pass wire

and reamer and nail.

Procedure for Both Positions

Point of Entry

Some people use a vertical midline incision, starting from the tuberosity proximally until the patella Splitting

the patellar tendon or retracting the patellar tendon laterally can gain access to the proximal tibia (Figs 2.12 and 2.13) The latter allows access to the tibia without splitting the tendon The advantage of the split

tendon approach is that it ensures the entry point in the midline It is shown now that when tendon is splitand surgery is done, no damage occurs to the tendon Anterior knee pain in interlocking initially wasthought to be related to injury to tendon, which is now shown not related

Diep The Hoa MD - HTO

8 Interlocking Nailing

A large curved bone awl is used to open the proximal tibial cortex anteriorly at a point 1-1.5 cm below

the joint line (Fig 2.14) In a smaller patient, it is just below the joint line I have experienced that at times the space

is so small that the starting point has to be just below the articular surface, and a risk of joint exposure exist, which is of

no clinical importance The point of entry has to be in the line of the medullary cavity The old K-nail of thetibia was a flexible nail, and the point of entry was medial to the tibial tuberosity, while the current interlockingnails are stronger nails and will not bend on entering the medullary cavity The center of the medullary

cavity is on the medial half of the tibial tuberosity (Fig 2.15).

It is not medial to the tibial tuberosity but is on medial half of tibial tuberosity A curved awl is taken, entered atthe chosen point, and directed posteriorly; once halfway in the bone, it is angled to go downward in thedirection of the medullary cavity Once this passage is made, a small non-cannulated rigid 7 -mm and later

8 mm reamer is inserted from this point of entry, connecting to the medullary cavity This step is a must Do

not start putting in the guidewire until the point of entry is connected to the medullary cavity, otherwise the nail insertion will not be done in the line of the medullary cavity

Fig 2.12: Split patellar tendon approach Fig 2.13: Medial parapatellar tendon approach

Fig 2.14: Curved bone awl entry into the medullary canal Fig 2.15: Point of entry on the medial half of tibial tuberosity, black

dot Straight line indicates midpoint of tibial tuberosity Diep The Hoa MD - HTO

Interlocking Tibia Nail

Problems of Point of Entry

If the point of entry is on the tuberosity, the tuberosity will avulse on introduction of the nail, and the nail

will be exposed in the upper part (Figs 2.16A to C) The tuberosity is not connected to the medullary cavity;

it is only a projection from the bone

If one is not in the midline but on the medial side, then reaming will be possible, as the reamer is

flexible But when the nail is introduced, there may be a fracture of the upper end of the tibia (Fig 2.17).

In case there is an old fracture with malunion, treated by plastering, you will have to choose the point of

entry in line with the medullary cavity, wherever it falls (Fig 2.18).

Figs 2.16A to C: Defective entry points (A) nail too out, (B) nail too in, (C) Avulsion of the tibial tuberosity

Fig 2.17: Fracture of proximal metaphysis following the introduction

of nail due to more medial point of entry Fig 2.18: deviation of entry point from routine entry pointChange in entry point in case of malunion—ProjectedDiep The Hoa MD - HTO

10 Interlocking Nailing

Reduction

When patient is on traction table, the reduction is always achieved and confirmed on C-arm before startingthe procedure In hanging leg position of reduction is achieved while passing the guidewire by applyingtraction, slight varus and flexion on the fracture site, and then guidewire is negotiated

Insertion of Guidewire

After connecting the point of entry with the medullary cavity, an olive tipped guidewire is passed into themedullary canal Closed reduction is carried out and the guidewire is negotiated into the distal fragment

Grating of the bone is felt when the guidewire passes through the distal fragment, and the bony end point is experienced

on pushing the guidewire distally It has been observed that if the guidewire has come out inadvertentlyafter reaming, this grating is not felt during reintroduction of the guidewire after reaming

Reaming

Successful introduction of the guidewire is confirmed with the C-arm, and then the tibia is reamed with aflexible reamer, over the olive tip guidewire The olive tip stops the reamer from progressing into the jointand helps in retrieval of the jammed or broken reamer if it occurs The tibia should be reamed to a size 1 to1.5 mm greater than the diameter of the nail that is to be inserted Alternatively, a nail 1 to 1.5 mm smallerthan the highest reamer used is chosen

There are a few surgeons who feel that power reamer should be avoided, to avoid heat necrosis of themedulla and they use only cannulated solid hand reamers As bigger size solid hand reamers will not beable to negotiate the isthmus and also it is difficult to ream tight isthmus with hand reamers They reamonly the proximal part of the medullary cavity and use thinner nail

I have always felt and used power reamer and used 9 mm nail most of the time in tibia and 11 mm nail

in femur Though occasionally one may not be able to ream more and may need to use 8 mm tibia and 10 mm

in femur This is very very infrequent in my practise

Insertion of Nail

After the medullary canal has been reamed to the correct length and

width, the olive tip guidewire is exchanged, without losing the reduction

of the fracture A flexible Teflon sleeve is passed over the olive tipped

guidewire until it is at the lower end of the tibia Teflon sleeves have a

small metal marker (Fig 2.19) close to their tip to facilitate localization.

After positioning the sleeve, the olive tipped guidewire is removed The

nontipped guidewire is passed down the tibia through it and the sleeve

is then removed

Assessment of Nail Length

Put identical length of the guidewire, to intramedullary guidewire, on

the level of bone point of entry Subtraction of the remaining exposed

guidewire from the total length of the equal size guidewire gives the

length of the nail A direct measurement of the guidewire which is

outside the bone which is not overlapping the inside guidewire gives

the length of the nail (Figs 2.20A and B) In mid-shaft fractures the nail

length is chosen so that the tip of the nail remains 1.5 to 2 cm proximal

to the end of the bone for future dynamization, if required

Fig 2.19: Distal end of femur with the wire The Teflon sleeve introduced over the guidewire is identified by the radiopaque marker anterior to guidewire (arrow) Diep The Hoa MD - HTO

Interlocking Tibia Nail

Alternatively, a radiolucent calibrated measuring

ruler can be used to measure the length of the nail

(Fig 2.21) This length can be checked again by

putting the chosen nail on the bone

The nail is then mounted on the insertion jig

If the medullary canal has been adequately reamed,

the nail can usually be pushed manually with

comparative ease, without hammering The last part

of nail introduction may need gentle hammering

While the nail is passing the fracture area, the

surgeon should keep the fracture well reduced, so

that iatrogenic fracture does not occur while

hammering the nail Nail should be pushed past the

fracture site, and once nail has entered the distal

fragment then only, hammer may be used to push

down nail finally Minor degrees of malreduction

can be corrected merely by the passage of the nail

over the fracture, particularly if the fracture is near

the isthmus Holding the jig, controls rotation of the nail when passing through the tibia After the nailhas been pushed into the distal fragment, the guide-wire is withdrawn All the nuts and the screws on thejig are tightened if they have become loose while hammering the nail The traction on the bone is releasedand the foot is thumped to push the distal fragment proximally and thus impact the fracture The distallocking screws are then passed as described below The distal-most screw is inserted first The guidewire

is reintroduced in the nail The metal sound produced by contact of the guidewire with the interlockingscrew confirms that the screw is within the nail and not outside Then the proximal screw of the distaltwo screws is inserted and the guidewire similarly confirms its presence Then the proximal lockingscrews are passed with the help of the premounted jig after back slapping the jig to achieve the impaction

at the fracture Confirm that the limb is in proper rotation while passing the proximal screw (Fig 2.22).

Use nail of 1 or 1.5 mm smaller than the last reamer used In mid-shaft and proximal fractures the distalend of the nail should be about 2 cm short to allow dynamization later But in distal tibia fractures nail must

be subcondral to get maximum stability

Figs 2.20A and B: Measurement of nail length by two-wire method Fig 2.21: Ruler placed on the bone and with C-arm, and direct reading

Fig 2.22: Distal fragment in external rotation The distal screws be removed and reintroduced through different cortical holes after correcting the rotation

A

B

Diep The Hoa MD - HTO

12 Interlocking Nailing

DISTAL LOCKING

An image intensifier is used for distal locking A mechanical aiming device to do distal locking, fitted to theproximal side of the nail does not work consistently All the nails, change shape on being passed down themedullary canal of the tibia and the distal screw holes do not end up correctly aligned with the jig, unlike inproximal locking where the distance is short and nail torsion does not occur

There are various techniques described for locating the distal holes:

1 Free hand with C-arm

2 The use of a special distal aiming device attached to the C-arm (Grosse Lafforgue device)

3 The use of radiolucent drilling handles

4 With the help of laser

5 With sonography

6 The use of the Orthofix device later adopted by AO where a proximally mounted jig is used for distallocking

7 The author’s method without C-arm

The time required for distal locking is more than for proximal locking and carries a higher risk ofradiation to the patient and the surgeon

Steps

Free Hand Technique

The patient’s leg is positioned between the source of the X-ray beam and the aiming device The imageintensifier is positioned so that the locking hole appears as a perfect circle on the monitor This is an importantpoint; any oval-shaped hole is not acceptable Position the image intensifier so that the distal locking hole is

in the center of the monitor and not at the edge Magnify the image of the hole It is easier to insert a screwwith a magnified image Then adjust the C-arm in such a position as to get a perfect round circle on thescreen and only then proceed with the distal locking If the image is not round but oval, it must be corrected

to achieve the round circle

There are three different types of oval shapes, which can be seen on the image intensifier depending onthe position of the limb in relation to the image intensifier The image will get resolved by moving the imageintensifier in one direction, i.e either in horizontal or a vertical arc or it will have to be moved in both these

planes, as shown in Figure 2.23 Do not change position of the limb to make circle round when hanging leg

position is used Leg is generally externally rotated and flexed at knee and rested on the operation table

(Fig 2.24).

Fig 2.23 Fig 2.24: Normal supine position and knee bent to pass wire and

reamer and nail Diep The Hoa MD - HTO

Interlocking Tibia Nail

After the circle has been located, following routine is suggested First under C-arm, mark the skin alongthe longitudinal axis of the nail Then draw another horizontally at 90° to this line on skin at the level of the

hole; this makes an entry point of the locking screw on skin (Fig 2.25).

Once this level has been found, the Steinmann pin is introduced on the bone to mark the point of entryfor the locking hole using a radiolucent rod, to avoid the exposure to the hands of the surgeon Once thepoint is located with Steinman pin, use hammer on the Steinman pin to make a pit on the bone to mark the

starting point at which drilling can be started (Fig 2.26) In cortical bone, Steinman pin does not mark easily

and if you use Hammer more energetically it will make a crack in the bone It is easy to mark on thecancellous bone So, if distal locking is done at lower end of the bone where cancelllous bone is present, thismark with Steinman pin will be easily done If nail stops at the cortical bone and distal locking is planned atthat level, then I feel direct drilling with the drill sleeve to avoid the loosing of the point is more fruitful.The drilling can be done on this point confirming on C-arm The self-cutting fixation bolt of a proper size, asmeasured by depth the gauge, is inserted through the protection sleeve

I have observed, that in early learning phase, and trying to lock percutaneously is more demanding andtime-consuming, compared to locking with an incision made until the bone

Make a skin incision long enough extending for both screws

Expose the bone and put two spikes Under the C-arm, localize

the point for locking, and make a bone impression with the

K-wire, so the drill will not skid Now drill the hole When an attempt

is made to drill at the chosen site percutaneously, the drill skids

and the chosen site is lost and the whole procedure has to be

repeated Locating the hole becomes easy and quick, when an

incision is made and the center of the bone is visible

C-arm Mounted Jig: Gross Lafforgue Device (Fig 2.27)

The sterile jig mounted on the C-arm is first adjusted by the

radiology staff so that the perfect round of locking holes is seen

on the screen, then the surgeon puts the protection sleeve on this

jig and puts the screw in the usual way

Fig 2.25: Normal supine position and knee bent to pass wire and reamer

and nail Mark on the skin Fig 2.26: Use of radiolucent handle for distal interlocking

Fig 2.27: Use of Gross-Lafforgue device (C-arm mounted jig) for distal interlocking Diep The Hoa MD - HTO

Navigation System

Navigation system now can easily locate the hole without X-ray exposure to the surgeon

After the operation, the patient is advised partial weightbearing, and then full weightbearing as per

patient comfort in noncommunited fracture.

Distal Locking if the C-arm Conks Out during Surgery

Distal Locking without C-arm

In the uncomfortable event that only available C-arm conks out after anesthesia and when surgery hasalready started, nailing and locking is yet to be done, I am describing this following procedure whereoperation can be completed I had described this method in JBJS (B) 1994 for using locking nail withoutC-arm

Nailing can easily be done once guidewire is passed and we can check it up with X-ray Nail is introducedand now distal locking is carried out If free hanging knee position is used, with jig attached to the proximal

end, rotate the hip in external rotation and flex knee (Fig 2.25) and adjust it on the table so that leg is

resting steady on the operation table Take an same length nail to that which is inserted in the tibia Keep

that nail on the surface of the medial side of the leg which is resting on the table (Fig 2.28) Adjust the nail

so that proximal end is matching Draw a line from the proximal end, on the upper level of the inserted nail

Fig 2.28: Identical nails Fig 2.29: Make a marker on skin seeing in C-arm at the site of hole Diep The Hoa MD - HTO

Interlocking Tibia Nail

(Fig 2.29) Now take the other identical nail, and adjust it matching this skin line on the upper end Hold it

firmly and put sterile tape if available Ethistrip or adhesive skin drape is useful Now nail strapped on thesurface matched on the inserted nail and skin marked of the locking distal holes, draw line at the distalholes on the skin Now remove the nail So that skin marking of the nail is present on the medial; side of thenail On the approximate point of distal locking holes, pass K wires on these two points as if they are exactly

on point on the skin Two K-wires of 2 mm diameter are drilled through which are supposed to roughlymatch the hole in tibia but not lie exactly over it an X-ray is taken to see the relation of the tip of the K-wire

and the distal locking holes inside the nail (Fig 2.30) The wires are removed, a single incision made on the

lower end of the tibia medially The periosteum is elevated, and the impression made by the drilled K-wires

on the bone is located

The correct drilling point for locking is judged from the radiograph

This is called the “Judged point” Study the radiograph and accordingly

Select a point exactly on the hole of the nail inside,

by viewing the relationship of the tip of the K-wire

passed earlier and the location of the hole in relation

to this K-wire (Fig 2.31) After localizing the judge

point a second K-wire is used to make an impression

on the judged spot, so that the drill does not skid

(Fig 2.32) 4.5 mm drill hole is made in the near cortex

at the judged point This hole is countersunk to improve the angular vision inside the tibial medullarycavity This hole is washed out with saline to remove blood and to clear the view inside the tibial medullarycavity a thin gauze piece can be used to clear this hole for better visibility In spite of the tourniquet a smallamount of oozing does occur Using a 3 to 4 mm suction tip and a good light source vertically down, one cansee the hole inside the tibia nail and a K-wire can be used to feel it Once the hole is located, takes a 3.2 mmdrill bit and manually inserts it through the hole in the near cortex and in the nail till it touches the oppositecortex Now, mount the power drill and drill the far cortex The cortex is drilled with a 3.2 mm drill throughthe hole, tapped and a 4.5-mm screw of the desired length passed If the drill bit is passed directly by powerdrill, there may be change in its direction, which may result in its breakage This works as a substitute foradjusting a perfect round hole on C-arm The same procedure is repeated for the other holes The corticalhole in the near cortex may be expanded in case of inability to locate the distal hole If this hole becomesbigger than a washer may be used This may happen in an early stage of learning curve

Fig 2.30: Radiograph showing the K-wires introduced with help of

another nail Fig 2.31: Drill hole made through the judged point may lie slightlyeccentric to the nail hole

Fig 2.32: Diagram to illustrate the method of drilling the second correct hole in the cortex adjacent to the eccentric hole Diep The Hoa MD - HTO

16 Interlocking Nailing

If the hole is not seen at this site where the tibia is opened

with a 4.5 mm drill there are 3 possible reasons:

1 The tibia hole is directly over the hole in the nail and

hence the metal is not visible

2 The tibia hole is far away from the nail hole Take another

X-ray by readjusting the guidewire

3 If only half the hole is seen

In some situations, the hole in the near cortex matches

the hole in the nail, but not exactly Thus only a part of

the hole in the nail can be seen through the cortical hole

(Fig 2.33) In this situation, drill another hole in the cortex

adjacent to the first While making this second hole, block the first hole with the drill bit This will preventthe drill bit from slipping into the first hole while making the second hole

A 4.5-mm cortical screw or bolt is introduced through the second hole after tapping the far cortex.Distal-most hole is locked first and confirmed with a guidewire passed from the upper end of the nail If thescrew is inside the nail, a metallic sound will be heard due to the guidewire hitting the screw This was verywell described as Tik Tok method of confirmation by Dr Shiv Shankar, Sholapur He also used this method

to locate the K-wire in the distal holes after locating that before putting the screw in the distal holes.Observe the distance, it is travelling down, this will get shorter as the locking progresses sequentiallyproximally, confirming the position of the screw in the nail After locking distally, it achieves compression

at the fracture, either by compression nail or by backslapping, on the proximal-end of the nail with a jig.Then proximal-holes are locked

With experience, the accuracy of distal locking by this method is 100%

TRAPS TO BE AVOIDED DURING INTERLOCKING TIBIA NAIL

1 Point of entry, above tibial tubercle in the center below joint level

2 Tendon splitting assures midline entry and knee can be flexed beyond 90°, if required

3 Keep fracture reduced while passing nail to avoid iatrogenic fracture

4 Do not lock when fracture is distracted

5 Nail size 1 to 1.5 mm smaller than last reamer

6 Correct length necessary, change the nail if nail not correct length

7 Adjust as perfect circle on the hole while distal locking by changing the C-arm axis

8 Keep distance between leg and C-arm longest for space for drill to work

9 In early, learning curve making an incision on distal end makes life comfortable

10 While drilling for distal locking, adjust drill straight in line of the hole

11 While removing the reamer keep guidewire pushed down

12 Read about small points of reaming in chapter on Reaming

13 Keep anterior of nail in line, avoids rotation of nail while introduction

14 Stabilize the fracture with hand and align them while passing nail, to avoid iatrogenic fracture

15 Push nail with hand across the fracture and start hammering only after fracture is bypassed

Fig 2.33: Final relationship of the two holes

in the near cortex Diep The Hoa MD - HTO

3 FFFFFracture of the Tibia racture of the Tibia Lower One-third

Lower one-third fractures are a very special problem The tibia has a good uniform medullary cavity untilthe junction of the upper two-third and lower one-third At this junction, the medullary cavity starts expanding

upto the subchondral bone at the ankle (Fig 3.1).

The nail has a good hold in the upper fragment It has a poor hold immediately at the fracture and justdistal to it A good mechanical fixation is the one where the nail has a good bony contact on both sides of thefracture for at least 5 cm In lower one-third fractures, this hold is poor distally The distal locking screwalso gives better stability if the holes are away from the fracture, which is not possible in the lower one-third fractures At least two locking bolts are necessary for stability It is advisable to use a nail which hasdistal screws at the lower most end of the nail and which is placed nearer, so that distally two screws can be

passed (Fig 3.2).

Most of the newly available nails are designed for this Shorter intervals between distal locking screws,

and if desired at right angles to each other is provided in these new nails (Figs 3.3A to C).

Lower one-third fractures are very easy to reduce by closed methods but if the guidewire goes to eitherside in the distal medullary cavity, and not in the center of the bone, angulation will develop at the fracture

site while passing the nail (Figs 3.4 and 3.5).

Fig 3.1: Widening of the medullary cavity in the lower

one-third of tibia Fig 3.2:Tibia (standard) Nail to be used for fractures of distalone-third tibia with locking at tip Diep The Hoa MD - HTO

18 Interlocking Nailing

Fig 3.3:Distal end can take 3 screws in different directions

Fig 3.4: Malunion of fractures of lower one-third of tibia in valgus

due to the eccentric position of nail Fig 3.5: Nail is eccentric giving deformity

Therefore, from the beginning, the guidewire in these fractures must end at the center of the tibia Toensure this, keep the fracture reduced well while inserting the wire in the distal fragment If the guidewire

is not in the center of the bone, the following procedure is done Withdraw the wire till the fracture site,and then reduce the fracture perfectly, push a thinner nail over the guidewire and push that nail into the

lower fragment in the corrected position, taking with it the guidewire (Fig 3.6) Withdraw the nail leaving

guidewire behind and then proceed with reaming and nailing in the routine manner If you try to reintroducethe wire alone, in center of the tibia, it will tend to go in the same track

This can also be achieved by passing Schanz pin in only one cortex on lower fragment and then reducethe fracture and pass the guidewire in the center Polar screw inserted in the path of a nail, going in the

undesired direction will also direct the nail in the center (Fig 3.7).

Diep The Hoa MD - HTO

Lower One-third Fracture of the Tibia

Figs 3.6A to F: (A) If guidewire not centric (B) remove wire reduce

fracture (C) pass thinner nail with wire till fracture and push thinner

nail in center (D) remove thin nail keeping wire (E) ream (F) pass

appropriate nail

Fig 3.7: Polar screw—the screws are inserted along the sides of medullary canal to introduce the nail in the center of the medullary canal in distal fragment

so introduce screw slightly above this spot and push it in We are changing the track and hence preferably

2 blocks will have to introduce in the projected path at a distance

of about 2 cm to each other

It is also suggested that you make a tract in which the guidewire

will travel by making cluster of screws 2 on one side and 1 or 2

other side of the tract so that nail will travel in this path only

(Fig 3.8) Practical observation is that guidewire will pass but when

after reamer when we try to pass nail, nail directly hits the polar

screws which we have put as exact diameter of nail may be bigger

than the space created This can be solved by keeping the guidewire

in the center till it is hammered in subcondral bone of the lower

end Now ream, which is going to be in correct place Once having

reamed and the guidewire is subcondral, now remove the polar

screws and pass the nail, nail has to pass in the desired centre

position of the medullary cavity With experience this problem

becomes infrequent Instead of the polar screws, one can also use

thick wires temporarily to redirect the nail in the proper direction Fig 3.8

Diep The Hoa MD - HTO

20 Interlocking Nailing

and can remove the K-wires at the end of the procedure (Figs 3.9 and 3.10) The question is asked whether

polar screw if it is introduced should it be removed at the end of properly directed nailing My view is it isnot needed after nail is properly directed and can be removed at the end of the operation This will help ifanother surgeon interprets as a failed interlocking screw and malign the original surgeon’s name Secondlight hearted view is, leave all polar screws in position as a policy, so that if ever any of the locking screwshas missed the hole, you can always say that it was polar screw which you had introduced and it is not themissed locking screw

The tip of the nail should be introduced fully into the distal subchondral bone to increase the stability

of the construct

Generally, lower one-third fractures are

accompanied by fracture of the fibula at the same

level Fixation of the fibula increases the stability of

these fractures If the fracture of the fibula is at the

same level and is not communited, plating the fibula,

or nailing the fibula, before nailing the tibia is

advisable (Fig 3.11) This will ensure that the tibial

guidewire will go in the center However, if the

fibular fracture is greatly communited and it is not

possible to establish normal anatomy, and if the fibula

is first fixed in a mal-position, then the tibia will also

be in malposition In such a case, it is recommended

to first fix the tibia by putting a guidewire in the

center without any deformity and then to fix the fibula

in the position it is lying (Figs 3.12A to C).

Do not ever dynamize by removing distal screws

in distal tibia fracture (Figs 3.13 to 3.15).

For practical purpose dynamization does not work

in distal tibia delayed union, I am making a drastic

Figs 3.11A and B: Prior fixation of fibula with plate could correct the angulation at the fracture of tibia (A) Prior fixation of fibula with plate could (B) Intramedullary wire is an alternative in transverse fracture

Diep The Hoa MD - HTO

Lower One-third Fracture of the Tibia

Fig 3.12: In comminuted fibula first pass nail in center

Fig 3.14: Oblique fracture Fig 3.15: Dynamization at near fracture is not good I would

choose, distal locking plate

statement, but this is my gut feeling Distal tibia healing is not by profuse callus like isthmus fracture Lowerthe fracture lesser the callus It heals more like a cancellous bone and hence bone approximation is moreimportant here Nail it, thump it on the foot, put distal screws, back slap on upper end and lock proximally

If available, use compression nail as described elsewhere

Distal tibia oblique fracture is a different fracture than transverse fracture Do not lump them as distal

tibia fracture So many times fracture line goes till ankle joint, this fracture should be treated by interfragmentalscrew and 3.5 neutralizing locking or simple plate I feel distal tibia oblique and spiral fractures should be

treated by interfragmental screw and neutralizing plate Distal third transverse fracture should be treated by

interlocking nail; with 2 distal screws. The open reduction and internal fixation of fractures of the lower third

Diep The Hoa MD - HTO

22 Interlocking Nailing

and lower fourth of tibia by plates and screws requires a special mention At times, it is difficult to pass twointerlocking screws in the nail in these fractures Also, in fractures with a large butterfly fragment openreduction and fixation of the fragment is necessary to obtain a good bony contact In these situations, theinterlocking nail is not an ideal implant The open reduction, interfragmentary screw fixation, and aneutralization plate are most suitable for these fractures I recommend the use of 3.5 mm reconstructionplate or precountered distal tibia locking plate, which is thinner, has 3.5 mm screws in lower end and

3.5 mm cortical screws in upper end for these fractures of tibia (Figs 3.16 to 3.32).

In elderly persons, these fractures occur in osteoporotic bones and, in the lower one-third fractures,there is bone crushing, which causes instability and delay in healing In such situations, I feel primary bonegrafting is very useful

Fig 3.16: Long oblique fracture lower one-third tibia treated with plate osteosyntheses Note interfragmentary screw

Diep The Hoa MD - HTO

Lower One-third Fracture of the Tibia

Fig 3.21 Fig 3.22: Had to make posterior incision to remove this

Fig 3.23: Locking plate Fig 3.24: 6 months united

Diep The Hoa MD - HTO

24 Interlocking Nailing

Fig 3.27: Distal 1/3 # Fig 3.28: Prebent plate

Fig 3.29: Oblique # Fig 3.30: 10 years Interfragmental screw with nail works ok Diep The Hoa MD - HTO

Lower One-third Fracture of the Tibia

TRAPS TO BE AVOIDED IN LOWER ONE-THIRD FRACTURES

• Fibula fixation is a must if both fractures at same level

• If fibula fracture is not communited, plate fibula first before tibia nailing, so that tibia guidewire will go

in the center

• If fibula fracture greatly communited, nail tibia first keeping guidewire in center followed by plating offibula in the position it is lying

• For maximum stabilization nail length must be long enough to remain subchondral in the distal fragment

• Guidewire should be in the center of tibia at lower end

• Choose a nail with the distal-most holes; all standard nails do not have this, beware

• We are not wedded to nailing, keep distal locking plate available when operating distal tibia which isnot a transverse fracture

• Transverse fracture nail Long oblique fracture plate

• Precountered distal tibia medial and lateral anterior plate are very good for distal tibia lower one-thirdand lower one-fourth fractures Oblique fractures many time extend upto distal end of tibia which can

be seen in good quality oblique X-rays

Fig 3.31: Oblique fracture Fig 3.32: Anatomical reduction and no plaster Diep The Hoa MD - HTO

4 One-four One-f Upper One-third and our ourth F th F th Fractures ractures

Upper one-third fractures are very tricky The AO type of nail is not helpful as the Herzog bend comes on

the fracture site giving an angulation to the fracture (Fig 4.1).

These fractures need the GK type of nail (Fig 4.2) The point of entry for these fractures is most proximally,

so that the nail can go in the proper line

Distinct angulation occurs at the fracture site while the nail is passing from the proximal fragment to thedistal fragment, until the Herzog bend is fully introduced After the nail is fully seated, the bone falls backinto proper alignment often not always

Most of the time, when the guidewire is passed, it initially tends to go posteriorly and comes out fromthe fracture site Holding the reduction with a towel clip or clamps percutaneously can control this It canalso be helped by passing a polar screw in lateral direction to block nail going posteriorly Use of the polarscrew has helped the nail positioning most of the time If it is not possible to control this segment, an openreduction may be needed Open reduction and 3.5 lag screw to stabilise the upper fragment is a good option

to get perfect alignment as seen in the Figure 4.3.

Fig 4.1: Angulation of fracture upper one-third tibia

at the Herzog’s bend of AO type Fig 4.2: GK type nail with a bend at the proximal most endDiep The Hoa MD - HTO

Upper One-third and One-fourth FracturesFor upper one-third, make a point of entry

proximally just underneath the articular surface and

then try to pass the awl and then guide wire parallel

to anterior cortex of proximal tibia so that line of

medullary cavity is met in direct line If one cannot

pass this guide wire properly then, open the fracture

and go to the anterior part of the proximal fragment

at the fracture site and pass a guide wire hugging

the anterior cortex from the fracture site retrograde

and come out from the point of entry This way the

nailing can be adequately done in these difficult

fractures

Intramedullarynail fixation of proximal tibial

fractures has a significant complication rate Malunion

after intramedullary nail fixation of proximal tibial

fractures is high Thedeformities, which occur, are

valgus angulation in the coronal plane, flexion

deformity in the sagittal plane, and posterior translationat the fracture site (Fig 4.4) Valgus deformity

occurs due to medial point of entry, which is not in same line in proximal fractures with medullary cavity It

is also contributed to some degreeby the shape of the proximal tibia The anterior-posteriorwidth of thetibia is much narrower on the medial side thanit is on the lateral side and the medial cortex of the tibiaforces the nail laterally The fracture that ismost typically seen in the proximal part of the tibia, beginsin thelateral aspect of the proximal part of the tibia andextends medially and distally Therefore, often there is nolateral cortex to help guide the nail distally and keep thenail aligned properly Once the nail engages thedistal segment,valgus angulation occurs because of the mismatch between theso-called nail entrance angleand the tibial canal.Additionally, the origin of the musculature of the anteriorcompartment acts as a tether

on the lateral tibial surface proximally,which may contribute to valgus angulation if any gap remains atfracture site during the nailing procedure

Flexion deformity is due the shape of thenail, and insertion of the nail with the knee flexed AO nailwith proximal bend contributes to anterior angulation and posterior translationaldeformities When thefracture is proximal to the bend in thenail, it can displace up to 1 cm, with the distal fragment typically

translating posteriorly in the sagittal plane (Figs 4.5 to 4.7).

Fig 4.3: Segmental fracture Tibia treated with interlock nailing Note the interfragmentary screw across the proximal fracture.

Fig 4.4: Valgus angulation at the fracture site following

interlock nailing for proximal third tibia fracture. Fig 4.6: when point of entry on lateral sideAngulation corrected

instead of medial sides

Fig 4.5: Flexion deformity

at fracture.

Diep The Hoa MD - HTO

28 Interlocking Nailing

SUGGESTION

The starting point must be placed at the edgeof the articular surface, it also be inside the joint on nonarticularsurface, just anterior to the ACL insertion This position is anterior to the axisof the medullary canal, so thenail initially must be directedposteriorly to enter the canal The inability to extend theknee during nailinsertion because of the presence of the patellacontributes to flexion of the proximal part of the tibia atthefracture site

There are several potential solutions to the problem of mal reductionof proximal tibial fractures duringnailing The most importantrecommendation is that the entry portal of the nail be madein line with the axis

of the medullary canal as possible.This is facilitated by use of a lateral portal placed high onthe tibia, at theedge of the articular surface This places the nail insertion site directlyover the medullary canal in thecoronal plane and as close aspossible to the axis of the canal in the sagittal plane Furthermore,this entryportal has been shown to reduce the strain withinthe cortex during nail insertion Hernigou and Cohenadvocateda so-called anterior approach to the proximal part of the tibiathrough the patellar tendon Tornettaand Collins recommendedthat a semi extended position with a partial medial knee arthrotomybe utilized

in certain circumstances This position bothneutralizes the deforming force of the quadriceps on the proximalsegment and allows the patella to be subluxated laterally, afterwhich the femoral trochlea can be used toguide the nail placement This approach provides ideal exposure of the ideal entrypoint without riskingknee pain from splitting the patellartendon In order to prevent the proximaltibial fragment from flexing,the nail must be placed as anteriorlyin the proximal fragment as possible

Another technical contribution to the management of malreductionof tibial fractures is the concept ofblocking (Polar) screwsas advocated by Krettek et al and by Cole This technique,which is simple toperform, involves the placement of bicorticalscrews into the tibia prior to introduction of the nail Thescrews serve to narrow the medullary canal in the tibial metaphysisand have been shown to increase thestability of the bone-nailconstruct Because proximal fractures are commonly orientedfrom distal andanterior to proximal and posterior, nails usedin proximal fractures are not forced anteriorly as they areinmidshaft fractures The blocking screw essentially functionsas a substitute posterior cortex, keeping the nailclose tothe anterior cortex as it is maintained in a midshaft fracture.Thus, the blocking screw is placed inthe posterior half ofthe proximal part of the tibia in the sagittal plane, blockingthe nail from passingposteriorly and abolishing the flexionand translational forces Similarly, an anteroposterior screwplaced

Figs 4.7A and B: (A) Anterior entry gives angulation (B) Posterior entry corrects

Diep The Hoa MD - HTO

Upper One-third and One-fourth Fractureslaterally in the metaphyseal region will substitute for

the lateral cortex, keep the nail at midline, and prevent

valgusdeformity Proximal locking screws from the

tibial nail setshould be used for the blocking screws,

and they may be leftin place after the nail is locked

Two proximal screws thatare perpendicular to one

another should be used when possiblefor proximal

locking

Tornetta et al reportedon seventy-three proximal

fractures for which they had usedan algorithm to

decide (Fig 4.8) if any special techniques were needed

to maintain reduction during nailing In theoperating room, they make a lateral radiograph of the tibia with the knee in flexion. If the fracture goes into anteriorangulation, they use a semi extended approach If posteriortranslationoccurs, a blocking screw is utilized If both deformities arepresent, both techniques are used.Other techniques that havebeen advocated to prevent malreduction of the proximal partof the tibia includeprovisional reduction and fixation of thefracture with unicortical plates or a distractor

If the fracture is too proximal then plating may have to be considered If the fracture is comminuted inelderly patients with porotic bones, nailing with massive grafting is necessary Crushed porotic bones donot heal just because closed nailing is done which happens as a rule in young patients This is my observation

in all porotic-crushed fractures of the femur, tibia, and femoral neck; they behave differently from comminutedfractures in younger patients

I think last is yet not said on managing the proximal tibia fractures Due to all these problems and

solutions suggested in literature there is still a major problem of malunion of these fractures (Figs 4.9 and 4.10) Alternate treatment of locking plate is now a viable solution I have almost fully changed over to

locking plates in proximal fractures

LOCKING PLATE FOR PROXIMAL FRACTURES

With advent of locking plate I feel now this is as good option or according to me better option in treatingproximal tibial fractures

Fig 4.8: Algorithm for managing proximal tibia fracture

Fig 4.9 Fig 4.10: Angulation of tibia (Three months) Diep The Hoa MD - HTO

2 or 3 locking screws in the distal fragment You may remove the non-locking screw at the end and substitutewith locking drill and screw if needed Otherwise that hole may be kept empty If the reduction is notobtained, miniopen reduction can be done, with minimal damage to the soft tissue all around Put screws indistal fragment by opening it with one incision or little short incision seeing in C-arm, only alternate holes

in distal fragment are filled up with screws In communited fracture if closed reduction is done no grafting

is needed If open reduction was needed and there is marked comminution with bone void, calcium phosphatebone substitute is ideal filling material

This is the treatment of choice for me for upper tibia fracture (Figs 4.11 to 4.16).

Fig 4.11: Precountered plate Fig 4.12: Preoperative

Fig 4.13: Perfect alignment (Nine months after plating) Fig 4.14: Preoperative

Diep The Hoa MD - HTO