Intramedullary nailing of tibial shaft fractures is a mainstay of treatment for orthopedic surgeons managing these injuries. Innovation and modern technology have allowed for significant advances in implant design during a relatively short time period. As surgeons have gained more experience with this procedure, advances have also followed in the surgical approach.

In the recent past, the standard technique for intramedullary nailing of tibial shaft fractures required the use of either para-patellar or patellar tendon splitting approaches. More recently, the semi-extended and suprapatellar approaches have been developed with a substantial amount of research reported for the benefits of this technique.

The suprapatellar approach, when correctly performed, allows for less manipulation of the fractured extremity, less work against gravity, minimal intraoperative assistance, fewer and easier fluoroscopic views, and greater ease with instrumentation and implantation. Biomechanical testing has shown the specialized instruments required do not increase joint pressure significantly and do not cause cartilage injury. Arthroscopic evaluation post implantation identified no iatrogenic patellar-femoral injury. Studies have also reported lower OR and fluoroscopy times, no worse outcomes and clearly less anterior knee pain, an issue that is both well-reported and problematic when using standard infrapatellar approaches. We use this case of a 48-year-old man who sustained a closed distal third tibial shaft fracture (Figures 1 and 2) during a recreational hockey game to highlight our surgical technique using the suprapatellar approach.

An AP radiograph of the injury is shown.

A lateral radiograph of injury, as seen here.

A foam ramp is secured to operating table under the affected extremity.

The injured extremity is shown with a bump under the hip to place the knee in neurtal rotation.

Images: Shah AR and Sanders RW

The patient was brought to the operating theater and placed on a radiolucent OR table in the supine position. A radiolucent foam ramp was secured under the affected extremity (Figure 3). This allowed for unobstructed fluoroscopic views (Figure 4). A bump was placed under the hip of the affected extremity to place the knee in neutral rotation (Figure 5). A high-thigh tourniquet can be applied, but is rarely used. In this specific case, the spiral fracture was reduced and provisionally held with a pointed reduction clamp through stab incisions (Figures 6 and 7).

An intraoperative AP image of injury is seen here.

The fracture is reduced and held with a reduction clamp.

Landmarks for the procedure are shown. The box represents the tibial tubercle. The dotted circle outlines the patella, and the line with hash marks represents the proposed surgical incision.

A skin incision is performed. The underlying quadriceps tendon is exposed.

A 3-cm to 5-cm longitudinal incision was made 2 cm superior to the patella (Figure 8). The incision required was just large enough to allow for insertion of the cannula. The quadriceps tendon was then split in line with the incision (Figure 9). A specialized blunt tip cannula was inserted in the retropatellar space down to the proximal tibia (Figure 10). A starting pin was placed through the cannula to the desired starting point (medial to the lateral tibial spine for shaft fractures), and further lateral for more proximal fractures (Figures 11 and 12). Once the starting point was obtained, the cannula was secured into the femur with a pin (Figure 13). This maintained the cannula in a protective position during instrumentation and implantation.

A specialized cannula is placed into the retropatellar space.

This AP film shows the starting pin.

This lateral film shows the cannula and starting pin.

The cannula is secured to distal femur with the pin.

An opening reamer was used and a ball-tipped guide wire was passed for the length of the tibia (Figures 14 through 17). While not needed in this case, cortical substitution or “blocking” screws/pins can be placed to recreate a deficient cortex to allow for appropriate placement of the guide wire. Care was taken to place the ball-tip guide wire in a center-center position in the distal tibia, as the nail will follow the path reamed (Figures 18 and 19). Reaming proceeded in a sequential fashion, until “chatter” was encountered. Our recommended reaming is 1 mm to 1.5 mm greater than the nail diameter.

The opening reamer is placed through the cannula.

This radiograph shows the opening reamer. Note that the cannula is protecting the retropatellar space.

The ball-tip guide wire is placed central in distal tibia on the AP view.

The ball-tip guide wire is placed central in distal tibia on the lateral view.

Proposed placement of a “blocking” pin if needed, is shown here.

If a “blocking” pin was placed, this image demonstrates how it would be used to direct the path of the reamer into the desired location.

The intramedullary nail with an attached “extended” insertion handle is shown.

Tibial nail insertion is performed.

Suprapatellar capable systems have extended nail insertion handles that account for the distance traversed in the retropatellar space (Figure 20). The nail was inserted through the cannula with ease, and the limb had not been flexed, extended or significantly manipulated throughout the procedure (Figures 21 through 23). Distal interlocks were placed without having to remove the insertion handle or repositioning the leg, as is often required with infrapatellar approaches to release pressure on the anterior tibia, distal femur and patella by the insertion handle.

Note that the cannula continues to be maintained in the retropatellar space.

The tibial nail is seated. The “extended” insertion guide traverses the cannula.

A final intraoperative AP film of the proximal tibia is shown.

This is the final intraoperative lateral film of the proximal tibia.

The nail was then locked proximally (Figures 24 through 27). The radiology technicians needed only to work the C-arm between AP and lateral views. The insertion handle was disengaged, and the joint was irrigated through the cannula. Wounds are irrigated and closed in a layered fashion and covered by sterile dressings.

Suprapatellar nailing of tibial shaft fractures is the next advance in the surgical management of these injuries. When performed appropriately, with specific attention to maintaining the cannula in the retropatellar space, suprapatellar nailing is a safe and effective method. The benefits of surgical ease and potentially less postoperative anterior knee pain make this not only an attractive, but possibly, a better approach for intramedullary nail insertion when treating tibial shaft fractures.

Disclosures: Shah reports he is a paid consultant for Smith & Nephew and StabilizOrtho. Sanders reports he is a paid consultant for and receives royalties from Smith & Nephew, Zimmer Biomet, Stryker and Linvatec.

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