The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 93, Issue 16

Selected Instructional Course Lecture | August 17, 2011

Surgical Techniques for Complex Proximal Tibial Fractures

Jason A. Lowe, MD¹; Nirmal Tejwani, MD²; Brad Yoo, MD³; Philip Wolinsky, MD³

¹ University of Alabama at Birmingham, 510 20th Street South, FOT 960, Birmingham, AL 35294
² NYU Orthopedic Surgery Associates, 301 East 17th Street, Suite 1403, New York, NY 10003
³ Department of Orthopaedic Surgery, University of California Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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An Instructional Course Lecture, American Academy of Orthopaedic SurgeonsPrinted with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in February 2012 in Instructional Course Lectures, Volume 61. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

J Bone Joint Surg Am, 2011 Aug 17;93(16):1548-1559

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Traditional and Alternative Surgical Approaches to the Tibial Plateau: How to Select Them?

Any surgical approach for fracture fixation should facilitate visualization of fracture fragments and allow the application of optimal fixation devices and soft-tissue repair. Treatment goals applied to tibial plateau fractures include anatomic articular surface reduction, restoration of the anatomic axis, and preservation of the menisci. The approach should not devitalize soft tissues or cause further injury to surrounding structures. An ideal surgical dissection encompasses these principles and permits early joint motion.

The midline longitudinal incision is the favored approach to the knee joint, as this incision facilitates knee replacement if needed in the future. Surgical exposure for complex injuries (bicondylar fractures) requiring dual fixation needs large medial and lateral flaps that add to soft-tissue complications. Other surgical approaches allowing a more direct approach to the fracture to decrease the risk of soft-tissue injury from excessive retraction or periosteal stripping are available. When one incision does not adequately expose the fracture, it is better to use a dual incision than a single midline exposure^1-3.

Anterolateral Approach

The anterolateral approach is used for the most commonly seen tibial plateau fractures (Schatzker⁴ types I, II, and III). It is also used for the lateral part of a dual incision approach needed for internal fixation of a bicolumnar fracture. The incision is centered on Gerdy's tubercle and is shaped as a lazy S or a hockey stick. The fascia is elevated off the tibial tubercle to expose the lateral tibial plateau. The knee capsule is incised, and a submeniscal arthrotomy allows visualization of the articular surface (Figs. 1 and 2). In addition to visualization of the articular surface, this approach allows repair of any meniscal tears.

Fig. 1

Clinical photograph of a patient's right knee with the lazy-S incision used for internal fixation of a lateral proximal tibial fracture.

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Fig. 2

Clinical photograph of a patient's right knee with retention sutures in the lateral meniscus (white arrow) of a submeniscal arthrotomy.

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Medial Approach

The medial approach is used for a medial tibial plateau fracture (Schatzker type IV) or as part of a dual approach to the plateau. The incision parallels the posteromedial border of the proximal part of the tibia. The pes anserinus is elevated, the fracture reduced, and fixation implants are placed beneath the pes anserinus. The pes anserinus may either be retracted (Fig. 3) or incised, with repair after fracture fixation. The medial meniscus cannot be elevated as is possible with the lateral meniscus; therefore, the limitation of this approach is the limited visualization of the articular surface of the medial plateau. Also, access to the posterior plateau is limited, but the medial approach can be converted to a posteromedial approach.

Fig. 3

Clinical photograph of a patient's left knee with a medial incision (patient's head is to the left). The tendons of the pes anserinus (white arrow) are seen over the clamp.

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Anterior Approach with Tibial Tubercle Osteotomy

The advantage of the anterior approach with osteotomy of the tibial tubercle is that the tibial plateau and the intercondylar notch are completely exposed, allowing reattachment or primary suture of the cruciate ligaments⁵. This approach is rarely used, and most complex, bicondylar fractures are now treated with use of dual incisions.

Posteromedial Approach

Medial tibial plateau fractures extending to the posterior aspect of the tibial plateau, posterior metaphyseal fractures, or those that require a buttress on the posteromedial cortex are best fixed with use of the posteromedial approach. Fragment-specific fixation of the medial plateau is recommended over stabilization with a laterally based locking construct⁶. To obtain optimal fixation of bicondylar fractures, a dual plating technique is recommended, with one plate fixing the medial fragment and one fixing the lateral plateau. Medial plateau fractures may be medial or posteromedial, with each requiring a plate to be, ideally, placed at the apex of the fracture (fragment-specific).

The patient can be positioned prone or supine⁷. An incision is made over the posteromedial aspect of the knee (Fig. 4). Dissection between the medial head of the gastrocnemius muscle and the semitendinosus muscle allows exposure of the semimembranosus muscle, which is detached for better access to the posterior aspect of the tibia. Visualization of the articular surface is limited, but, if necessary, visualization can be improved with a longitudinal split in the medial collateral ligament and capsule. Through this incision, visualization of the articular cartilage can aid in congruent joint reduction.

Fig. 4

Clinical photograph of a patient's right knee. With the patient in the prone position, the solid line identifies the level of the knee joint with the femur to the left. The dashed line illustrates an incision for a posterior-medial incision.

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Posterior Approach

An isolated posterior shear fracture, a posterior cruciate ligament avulsion fracture with a large osseous fragment, or a posterior fracture dislocation is best exposed with a posterior approach^8,9. A z-shaped incision across the flexor crease is used. The deep tissue planes are between the medial head of the gastrocnemius and the semimembranosus muscles or between the two heads of the gastrocnemius muscle with protection of the neurovascular structures. The medial or lateral head of the gastrocnemius muscle may be partially detached, if it is necessary to improve exposure, enable fracture reduction, or insert fixation on the posterior rim.

Extended Lateral Approach with Fibular Osteotomy

The Lobenhoffer approach is used to expose fractures of the lateral tibial plateau that extend posteriorly when the head of the fibula limits the exposure^10,11.

The skin incision is made along the course of the peroneal nerve, posterior to the fibular head. After dissection, the common peroneal nerve is protected and an osteotomy of the fibula at the junction of the head and neck is performed, leaving the proximal attachments intact. This allows exposure of the tibial plateau from anterior to posterior.

Another way to approach the posterolateral plateau is without a fibular osteotomy¹⁰. Absence of an osteotomy makes it more difficult to visualize the tibial fracture at the level of the fibular head; however, this approach is preferred as it avoids the risk of a nonunion at the fibular osteotomy site.

Medial Tibial Plateau Reduction

A shearing force produces a coronal plane fracture comprising approximately 25% of the medial articular surface¹². This fragment is seen on a lateral radiograph, but the full extent of articular involvement is best appreciated on sagittal computed tomography (CT) images. Since the medial collateral ligament (MCL) prevents a submeniscal arthrotomy, reduction of the medial joint line is often obtained indirectly with anatomic restoration of the medial cortex. If there is a question about the accuracy of the reduction of the articular surface of the medial plateau, a longitudinal incision is made in the MCL, where the fracture enters the medial aspect of the joint. Anatomic reduction is confirmed by aligning the articular cartilage of each fragment while the cortex is reduced with a well-placed Weber clamp perpendicular to the fracture. This white-white read of the medial plateau articular cartilage augments accuracy of reduction.

Medial Plateau Fixation

Surgical stabilization of isolated medial plateau fractures (Schatzker type IV) is accomplished with an undercontoured, nonlocking, flexible plate (1/3 T-plate or reconstruction plate) applied as a buttress. Fixation of the medial plateau in Schatzker type-V and VI fractures is more controversial. Stabilization can be accomplished with locking screws placed through a laterally based implant alone or stabilized with a medial plate as part of a dual plating construct (medial and lateral plate)^13-17. Biomechanical and clinical data support both techniques. Although lateral-only locked plates reduce surgical time, blood loss, and limit soft-tissue stripping, a high rate of articular subsistence (26%) has been reported^13-17. Displacement of the medial fragment can result in knee instability, pain, and posttraumatic osteoarthritis¹². The authors, therefore, recommend fragment-specific fixation of the posteromedial and lateral plateau through a two-incision approach for bicondylar tibial plateau fractures. Fragment-specific fixation of the medial plateau avoids inadequate purchase of the posteromedial fragment observed with lateral-only locking screws^6,16-18. The benefit of added fracture stability is offset by greater surgical time and higher postoperative infection rates. Current reports have demonstrated postoperative infection rates of 8.4% with dual plating compared with 1.6% with lateral-only fixation^13,14. In the absence of a prospective, randomized, controlled trial comparing these surgical approaches, the need for anatomic reduction of the joint surface and adequate stabilization of the medial plateau takes precedence.

Lateral Plateau Articular Reduction

High-energy bicondylar tibial fractures are typically associated with articular surface impaction of the lateral plateau. Successful restoration of the lateral aspect of the joint requires adequate visualization and an array of reduction techniques. A submeniscal arthrotomy and a laterally based femoral distractor improve visualization of the articular surface when needed. A single Schanz pin is placed into the femoral metaphysis, parallel to the joint line, and a second Schanz pin is placed in the tibia, distal to planned plate placement location¹⁹. Care must be used with placement of a lateral tibial pin so as to not injure the neurovascular structures of the anterior compartment²⁰. Applying distraction opens the joint and enhances visualization of the lateral plateau. Retraction of the posterolateral or anterolateral fragments (opening the door) can allow even more visualization.

Mobile articular pieces are reduced with a dental pick or a small (0.45 to 0.62-mm) wire and are temporarily stabilized with Kirschner wires. Impacted articular fragments must be mobilized from surrounding cancellous bone before they can be reduced. A 1/4 to 1/2 in (0.64 to 1.3-cm) osteotome or bone tamp is used to elevate 1.0 to 1.5 cm of cancellous bone with the articular segment. Once levered into position, the fragment is stabilized with Kirschner wires. With the impacted segment reduced and secured with wire fixation, bone voids can be filled with graft material and the lateral segment can be reduced (closing the door). The medial and lateral plateaus can be reduced and compressed with a periarticular reduction clamp¹⁹.

The contained defect of a pure depression fracture cannot be reduced without an osteotomy. If there is an incomplete fracture, the articular segment is accessed by completing the fracture and reducing the articular fragment as described above. If there is no cortical fracture, articular reduction is done with one of two techniques. The anterior compartment is released from the metaphyseal flare for both. One technique is to use the DHS (Dynamic Hip Screw; Synthes, Paoli, Pennsylvania) set and fluoroscopic visualization. The guidewire is directed from the lateral tibial metaphysis toward the impacted segment. The cortex is then opened with the cannulated 11-mm reamer from the DHS system. Bone tamps are introduced and used to tap the articular segment into place. The articular reduction is confirmed by direct visualization through the submeniscal arthrotomy. Alternatively, a lateral osteotomy is made with drill holes (2.0-mm drill-bit) in a diamond pattern, with the drill holes connected with use of a 0.25-in (0.64-cm) osteotome. The articular segment is reduced as just described. With either technique, the articular fragments can be supported with Kirschner wires and bone graft prior to definitive fixation.

Lateral Plateau Fixation

Surgical stabilization of the lateral plateau must maintain reduction and rigid fixation of the articular segment to a well-aligned tibial shaft. The joint surface is stabilized with multiple parallel screws placed just beneath the subchondral bone. These rafting screws support the reduced articular surface fragments and can be the proximal screws of a 3.5-mm or a 4.5-mm, precontoured periarticular plate or with minifragment (2.4 or 2.7-mm) screws. Minifragment screws and plates are favored for articular comminution with fragments having minimal subchondral bone or when the proximal screws in the precontoured plate are not subchondral.

The articular segment is reduced to the shaft with traction (a manual or femoral distractor). First, the plate is fixed to the proximal segment with bicortical screws (locked or nonlocked) inserted parallel to the joint²¹. The plate is reduced to the tibial shaft with a bicortical screw or a so-called whirlybird push-pull type of device. It is important to ensure that this does not malreduce the fracture in the coronal plane, and locking screws should not be placed in the distal segment until the alignment is correct²².

Minimally Invasive Plate Osteosynthesis

The proximal tibial anatomy and fracture pattern must be clearly understood if precontoured plates are used with minimally invasive techniques. The articular surface is visualized with a small arthrotomy, and percutaneous techniques are used for screw placement into the tibial shaft (Fig. 5). One must be careful when this technique is used for plates longer than eleven holes, as the neurovascular bundles in the anterior and lateral compartments are at risk^12,23.

Fig. 5

Clinical intraoperative photograph of a patient's left knee, demonstrating incisions for minimally invasive plate osteosynthesis.

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Locking Screws

Locking screws increase construct rigidity, but they should be placed bicortically^21,24. They are useful in severely osteoporotic bone, substantial metaphyseal-diaphyseal comminution, or short-segment periarticular and/or intra-articular fractures. Malunion has been a problem, and it is necessary to pay meticulous attention to fracture reduction before placement of locking screws (Fig. 6)²⁵.

Fig. 6

Anteroposterior radiograph of a knee illustrating the inability of locking screws to reduce the valgus malalignment in the coronal plane. As a result, a valgus malunion, with the plate poorly apposed to the tibia, is observed.

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Intramedullary Nailing of Proximal Tibial Fractures

The use of an intramedullary nail for fracture stabilization is appealing. The insertion point of an intramedullary nail is remote from the fracture site, minimizing vascular disruption of the fracture fragments, the implants are centrally located, and tibial diaphyseal fractures have a high rate of union and low rate of complications. As a result, the use of intramedullary nailing for tibial fractures has expanded from mid-shaft diaphyseal fractures to proximal fractures^26-32. Intramedullary nail fixation is technically more demanding for proximal tibial fractures than for diaphyseal fractures. Unlike intramedullary nailing of a diaphyseal fracture, placement of the intramedullary nail does not reduce a proximal tibial fracture, and malreductions of proximal tibial fractures with intramedullary nail fixation are reported to be as high as 84%^27,33-36.

The typical deformity caused by intramedullary nailing of proximal tibial fractures is valgus and apex anterior angulation with anterior translation of the proximal fragment (Fig. 7). The valgus deformity is due to an imbalance of muscle forces on the proximal fragment and is accentuated when the insertion point is too medial or directed laterally. The tip of the nail can abut the lateral cortex causing the proximal fragment to rotate into a valgus position (Fig. 8)^34,35,37. The apex anterior deformity results from a combination of the pull of the patellar tendon³⁴, a distal insertion site, or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment (Fig. 9). Nails with an accentuated distal Herzog bend may translate the proximal fragment anteriorly, described by Henley et al. as the wedge effect³⁸.

Fig. 7

Fig. 7 Anteroposterior and lateral radiographs of an extra-articular proximal tibial fracture demonstrating the most common deformities (valgus and procurvatum) observed in these fractures. Fig. 8 Anteroposterior radiographs showing how a medial starting site produces a valgus deformity as the intramedullary device enters the tibial diaphysis.

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Fig. 9

Lateral radiographs showing how an inferior starting site and posterior nail trajectory produce a procurvatum deformity of the proximal segment as the nail enters the diaphysis.

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To prevent malalignment of proximal tibial fractures during intramedullary nailing, one should properly place the starting point; reduce the fracture prior to guidewire placement, reaming, and nail insertion; and hold the reduction until all of the locking bolts have been inserted.

The Proper Starting Point

Fluoroscopic imaging is used to obtain good anteroposterior and lateral C-arm images of the knee. The starting point on the anteroposterior radiograph is in line with the medial border of the lateral tibial spine (Fig. 10). The insertion site on the lateral radiograph is slightly anterior to the anterior margin of the articular surface. The guidewire and nail are inserted as parallel to the anterior cortex as possible (Fig. 11).

Fig. 10

Fig. 10 Anteroposterior radiograph demonstrating an appropriate starting site, just medial to the lateral tibial spine and in line with the mechanical axis. Fig. 11 Lateral radiograph demonstrating a correctly selected starting site and wire trajectory. The wire is just anterior to the articular margin and directed parallel to the anterior tibial cortex. Fig. 12 Anteroposterior and lateral radiographs with a protection sleeve for a retropatellar tibial nail centered at an appropriate starting site.

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Fracture Reduction Techniques

Extended Leg Position

It is critical to reduce the fracture and maintain the reduction during fracture fixation. The intraoperative position of the leg affects fracture reduction. When the knee is maximally flexed, which facilitates collinear insertion of the nail with the anterior tibial cortex, the pull of the patellar tendon increases the apex anterior deformity. When this occurs, the apex deformity can be limited by placing the instrumentation in the leg with minimal knee flexion³⁹. Originally, semiextended nailing was performed through a large medial parapatellar incision; however, it can now be done with a small suprapatellar incision. The instruments and nail are passed through protective sleeves, posterior to the patella to the proximal part of the tibia (Fig. 12)¹⁶. Recent studies have suggested this technique can be used without injury to the patella or femoral articular cartilage, the menisci, or the anterior cruciate ligament^16,18,40. No outcomes data are available for this technique.

Use of a Femoral Distractor or an External Fixation Frame

A universal distractor or an external fixator can be used to obtain and maintain fracture reduction. With use of fluoroscopic imaging, a proximal Schanz pin is inserted from the medial side of the proximal part of the tibia posterior to the planned intramedullary nail path (Fig. 13), and a distal Schanz pin is placed medially in the posterior malleolus (behind the nail) or at the level of the physeal scar (Fig. 14). The pins should be inserted parallel to the proximal and distal joint lines. Application of traction through the frame until the pins are parallel typically results in adequate reduction^34,41.

Fig. 13

Anteroposterior and lateral radiographs with a proximal Schanz pin for the AO distractor, appropriately placed parallel to the articular surface (left) and posterior to the nail path (right).

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Fig. 14

Anteroposterior and lateral radiographs demonstrating an appropriately placed distal Schanz pin inserted parallel to the ankle joint and posterior to the nail path.

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Temporary Plate Fixation

A small plate can be used as a temporary reduction device^29,42. The plate may be placed on the medial or lateral tibial border, but the medial border is better since the medial side of the fracture is often less comminuted. The medial incision is positioned posterior to the posterior borders of the tibia so that if the incision fails to heal, no bone will be exposed (Fig. 15). Minimal deep dissection is needed, and the plate is placed over intact periosteum. Unicortical screws are used so the reamer and nail can pass. After insertion of the nail and all interlocking screws, the plate may be removed or the screws on the proximal side of the fracture may be taken out. The plate then acts as a buttress construct, preventing a deformity from recurring while permitting relative motion at the fracture site.

Fig. 15

Anteroposterior and lateral radiographs with a provisional locking plate on the posteromedial tibial cortex. Unicortical locking screws are used so as to not obstruct insertion of reamers or the intramedullary implant.

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Blocking Screws

So-called blocking or Poller screws can be used during intramedullary nailing of proximal tibial fractures. They are placed preemptively in an effort to prevent a deformity or as a so-called bailout after deformity has occurred. They are used to narrow the canal, to create a path, or as an artificial cortex for the nail to pass down^28,33,43.

Blocking screws are inserted perpendicular to the plane of the deformity, on the concave side of the deformity, within the more mobile fracture segment. For example, with a valgus deformity, the screw is placed from anterior to posterior, on the lateral side of the instrument path, and in the proximal segment (Fig. 16). The screw functions as a so-called artificial cortex.

Blocking screws can also be used for an anterior malalignment. The blocking screw is placed slightly posterior to the midline, from medial to lateral, in the proximal fragment (Fig. 16). As a nail is inserted, it contacts the blocking screw, extending the proximal fragment and decreasing the apex anterior deformity. The screw should not be placed in the midline since nail passage may be blocked by the screw.

Fig. 16

Anteroposterior and lateral radiographs demonstrating proper positioning of blocking screws to aid in fracture reduction and strengthen the implant construct. Anterior-posterior screws placed lateral to the nail (white large arrows) prevent valgus deformation, and medial-lateral screws placed posterior to the nail (white small arrows) prevent procurvatum.

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Percutaneous Clamps

The orientation of a fracture line may allow percutaneous placement of a reduction clamp to obtain and maintain the reduction (Fig. 17). The use of clamps has not been shown to increase infection rates⁴⁴.

Fig. 17

Fig. 17 Lateral intraoperative radiograph with a Weber clamp placed percutaneously to hold the reduction during nail insertion. Fig. 18 Lateral intraoperative radiograph with a well-positioned guidewire (parallel to the anterior cortex) during reaming (left). Insertion of a nail with a low Herzog bend (black arrow) showing displacement of the proximal fragment as it contacts the posterior cortex (right).

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Implant Selection

It is important to know the implants in order to ensure that at least two locking screws can be placed in the proximal segment. The distance from the end of the nail to the locking bolts determines how far proximal or distal fracture lines can extend and still be stabilized by the intramedullary nail. The number and orientation of the proximal and distal interlocking bolts vary by implant. Oblique bolts have demonstrated more stability than transverse bolts in resisting coronal plane deformity, but not axial or torsional stability³⁸. The combination of oblique and transverse interlocking screws increases construct stability^45,46. Intramedullary devices with a distal Herzog bend may accentuate a sagittal plane deformity because, as the Herzog bend contacts the posterior cortex, it can create a so-called wedge effect and translate the proximal segment anteriorly (Fig. 18)³⁸.

Complications and Pitfalls

Knee pain, after intramedullary nailing of the tibia, affects 60% to 70% of patients^47-50. The anterior knee pain is exacerbated by kneeling, squatting, stair climbing, or high-performance athletic activities. Implant removal after fracture union has had inconsistent results with regard to relieving anterior knee pain. There is no difference in the prevalence of knee pain when a transpatellar or parapatellar incision is used.

The prevalence of malunion has been reported to be as high as 84%³⁶. With use of the techniques described in this article, malunion rates have been reduced to between 8% and 23%^28,29,31. Strict attention to surgical technique and the use of reduction aids decrease the prevalence of malreduction.

Infections and nonunions are most commonly associated with open and/or comminuted fractures^{29,31,36,42,51}. Ultimate union rates of 91% to 100% have been reported, but the union rate following primary fixation is approximately 77%^28,29,36,42. Lindvall et al. reported a 100% union rate for closed tibial fractures and a 23% rate of nonunion for open fractures stabilized with an intramedullary nail³¹.

Patient-specific contraindications to the use of an intramedullary nail include open physes, intramedullary canals too narrow to allow insertion of a nail, preexisting canal deformities, knee contractures, and so-called blocking hardware such as an ipsilateral knee replacement or knee fusion. Fracture-specific contraindications to the use of an intramedullary nail include substantial intra-articular involvement, and short extra-articular segments that preclude placement of at least two interlocking screws⁶.

Nails Compared with Plates

A literature meta-analysis found a trend toward an increased prevalence of malunion after intramedullary nailing compared with plate and screw osteosynthesis (p = 0.06), but a lower infection rate after intramedullary nailing (p < 0.05)⁵². Lindvall et al. also demonstrated a trend toward a higher malunion rate for intramedullary nailing (p = 0.103), a threefold increased rate of hardware removal after plate and screw fixation, and no difference in implant failure between these two techniques³¹. Both intramedullary nails and plates can be inserted with use of surgical techniques that respect the local soft-tissue biology. These techniques optimize fracture-healing and contribute to a high rate of fracture union for both operative procedures^27,29,52,53.

Implant failure has been reported for both intramedullary nails and plates^35,36,53. Early studies of intramedullary nails had implant failure rates as high as 25%, while only 2.6% of plates failed^36,53. Many early failures of intramedullary nails involved small-diameter locking bolts²⁴. More recent literature has demonstrated similar prevalences of implant failure for intramedullary nails and plates^{2,28,31,34,54,55}.

Overview

Extra-articular proximal tibial fractures are technically demanding fractures to treat. Fixation with an intramedullary nail requires a firm understanding of the anatomy of the proximal part of the tibia, the fracture pattern, the deforming forces, and the implant system. The prevalence of malreduction can be reduced with use of meticulous surgical technique, a correct nail insertion site, and adjuvant reduction aids. The rates of postoperative infection and nonunion are related more to the nature of the injury (open and comminuted) than to the implant. Patients should be educated on the occurrence of postoperative functional knee pain, which seems to occur more commonly in younger, more active patients.

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Topics

bone nails ; osteotomy ; tibia ; tibial fractures ; intramedullary nailing ; tibia fractures, proximal end ; fracture reduction ; tibial plateau ; proximal tibia ; locking screw

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Jason A. Lowe, Nirmal Tejwani, Brad Yoo, Philip Wolinsky; Surgical Techniques for Complex Proximal Tibial Fractures. The Journal of Bone & Joint Surgery. 2011 Aug;93(16):1548-1559.

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