Proximal entry for intramedullary nailing of the tibia

Abstract

T he risk of articular penetration during tibial nailing is well known, but the incidence of unrecognised damage to joint cartilage has not been described. We have identified this complication in the treatment of tibial fractures, described the anatomical structures at risk and examined the most appropriate site of entry for tibial nailing in relation to the shape of the bone, the design of the nail and the surgical approach.We studied the relationship between the intra-articular structures of the knee and the entry point used for nailing in 54 tibiae from cadavers. The results showed that the safe zone in some bones is smaller than the size of standard reamers and the proximal part of some nails. The structures at risk are the anterior horns of the medial and lateral menisci, the anterior part of the medial and lateral plateaux and the ligamentum transversum. This was confirmed by observations made after nailing 12 pairs of cadaver knees. A retrospective radiological analysis of 30 patients who had undergone tibial nailing identified eight at risk according to the entry point and the size of the nail. Unrecognised articular penetration and damage during surgery were confirmed in four.Although intramedullary nailing has been shown to be a successful method for treating fractures of the tibia, one of the most common problems after bony union is pain in the knee. Unrecognised intra-articular injury of the knee may be one cause of this.

Accurate Entry Point for Tibial Nailing with SIGN Nail in Asians: A Cadaveric Study

“…The ideal entry point for tibial nailing had been reported by several authors [2][3][4][5][6]. Samuelson MA et al [2] reported to be at the medial aspect of the tibial tubercle in coronal plane.…”

“…O Lembcke et al revealed that too lateral entry point caused a varus deformity and too medial entry point created a valgus deformity [3]. Hernigou P, Cohen D [4] revealed that 2.5mm (+/-1.8mm) lateral to the centre of the tibial tubercle is an ideal entry point. Too distal entry point leads to proximal posterior cortex breakage.…”

Anterior Knee Pain After Tibial Intra-Medullary Nailing.

“…The causes of knee pain are multifactorial and protruded nail alone cannot be blamed. Many intra-articular and extra articular structures are believed to be responsible for knee pain after tibia nailing [22][23][24] .…”

“…Hence they recommend entry point anterior to the transverse ligament and anterior horn of each meniscus 23 . McConnell et al,based on their study on cadaveric knees recommended entry point medial to the lateral tibial spine and anterior to articular margin to avoid articular cartilage damage 24 .…”

Long-term quadriceps femoris functional deficits following intramedullary nailing of isolated tibial fractures

“…The proximity of IM tibial nail placement to articular tissues may adversely influence knee extensor mechanism function [11]. The patellar ligament transfers the locomotion and dynamic knee joint control stabilizing forces of the quadriceps femoris muscle group to the lower leg during function.…”