Pearls & Pitfalls Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I Preparation check wounds - closed vs. open (start IV antibiotics immediately if open) assess soft tissue injury, compartments Positioning radiolucent table, radiolucent triangles, and C-arm from contralateral side Approach limited anterior approach to knee parapatellar vs. patellar tendon splitting Guidewire Insertion start point is anterior to articular plateau and medial to lateral tibial spine Fracture Reduction traction over triangle with anterior/posterior or varus/valgus pressure can use external fixation or femoral distractor to control length and alignment Reaming ream 1.0 above size of final nail Nail Insertion insert nail over guidewire, mallet in using strikeplate rotation should align with 2nd metatarsal Interlocking Screws targeting guide to place 2-3 proximal statically interlocking screws perfect circles for distal tibial medial to lateral interlocking screws Postoperative weight-bearing as tolerated immediate range of motion exercises to knee DVT prophylaxis serial compartment checks for 24 hours Planning & Preparation Extremity Exam need to check wounds for evidence of open fracture, assess lower extremity compartments document distal neurovascular status and associated injuries Characterize Fracture determine closed vs. open injury (if open start IV antibiotics immediately) amount of comminution degree of soft tissue injury need biplanar radiographs of entire tibia/fibula, knee, and ankle obtain CT scan with: distal 1/3 fractures (high rate of posterior malleolar fractures) proximal third fractures (joint line extension) acceptable alignment for closed tibia fractures: <5° varus/valgus, <10° anterior/posterior, >50% cortical apposition, <1cm shortening, <10° rotation can be placed into long leg cast and then a functional brace at 4 weeks Equipment & Positioning Equipment tibia intramedullary nailing system c-arm fluoroscopy radiolucent OR table optional: large sharp periarticular clamps or Weber-style clamps large external fixation system or femoral distractor Position patient supine with feet at the end of the bed, small bump under ipsilateral thigh need to move all lights away from area directly over OR table as this will get in the way of guidewires and reamers step stool to get better angle for reaming prep and drape with full access to foot and ankle to judge intraoperative length, rotation, and alignment OR Setup and C-arm radiolucent OR table c-arm from contralateral side, perpendicular to bed Approaches Anterior Knee plan out anterior approach to knee: medial parapatellar (most common), lateral parapatellar, patellar tendon splitting in cases of decreased knee flexion, can also use suprapatellar approach through superolateral aspect of patella incision and approach are made ~4cm proximal to the superior edge of the patella Surgical Technique Approach flex knee over radiolucent triangle and mark out inferior pole of patella, borders of patellar tendon, joint line, tibial tubercle make incision from inferior pole of patella distally 2.5cm towards tibial tubercle along medial 1/3 of patellar tendon spread down to dissect paratenon, identify medial edge of patellar tendon and incise retract patellar tendon laterally and spread down to guidewire starting point insert self-retaining retractor such as a Gelpi to maintain access Guidewire Insertion guidepin start point just medial to the lateral tibial spine on the AP radiograph on anterior cortical downslope on lateral view guidepin should be placed parallel with canal on AP view and just posterior to parallel on lateral view use soft tissue protector over guidewire use cannulated starting point reamer to open canal (drill to metaphyseal bone) remove starting pin and reamer, place balltip guidewire in canal with T-handle place gentle bend at tip of wire, manually push in to distal aspect of fracture site on C-arm Fracture Reduction reduce fracture by pulling traction over triangle can use small blue towel bump behind leg as a bump use mallet to hold pressure over fracture site can use intramedullary finger reduction tool and/or pointed reduction clamps through skin incisions once fracture reduced, manually push guidewire past fracture site to distal physeal scar check biplanar imaging to ensure wire is in canal measure nail length with ruler Traveling Traction if working alone or with untrained assistant, or if reduction assistance is needed, apply traveling “box” traction before knee incision can use femoral distractor over pins as an alternate to external fixator bars insert pins through posterior distal tibia and posterior proximal tibia (just anterior to fibular head but in posterior proximal tibia) Reaming start with size 9mm reamer, then ream up 0.5-1.0mm with each reamer push down through starting hole into bone before starting reamer this prevents eccentric reaming of your starting point can use step stool to get better body position for reaming if needed check chatter from reamer feedback and diaphyseal fit on C-arm imaging minimal to no reaming at fracture site to minimize eccentric reaming ream 1.0 above size of final nail (i.e. size 12mm reamer head for size 11mm nail) ream on full speed, slowly and deliberately, don’t stop reamer in canal (avoids reamer head from becoming incarcerated) if a distal fracture, don't ream the distal tibia unless the guidewire is in perfect position Blocking Screws if coronal or sagittal malalignment is noted, blocking screws are placed on the concavity of the deformity most commonly placed posterior or lateral to the guide wire in the proximal segment in proximal 1/3 fractures these screws serve as a pseudo-cortex to guide the nail these screws also serve to increase construct stiffness Nail Insertion build nail on backtable and make sure targeting guide lines up with holes in nail insert nail over guidewire and push into place manually as much as possible advance to fracture site and minimize mallet use at fracture site to minimize iatrogenic comminution insert nail fully and check lateral C-arm view at the knee to ensure the nail is sunk at or below the edge of the bone rotation of the nail should align with 2nd metatarsal if compression is needed across fracture site, insert distal interlocking screws via perfect circles technique then backslap distal fragment into proximal fragment must sink nail into proximal segment enough to allow backslapping remove guidewire before placing interlocking screws Proximal Interlocking Screws attach proximal targeting guide and mark skin with triple sleeves for 2-3 static holes use a 15 blade through skin, spread down to bone with hemostat, place trochar of sleeve on bone remove inner sleeve then drill through 1st cortex and nail when hitting 2nd cortex, stop and measure, call out length, then finish 2nd cortex (2nd cortex adds 2-5mm) remove inner sleeve and insert screw be careful not to over tighten screws as they can sink into bone easily in metaphyseal bone repeat process above for placement of other interlocking screws if indicated can lock screws proximally into nail if the instrumentation allows remove targeting guide and jig from nail Distal Interlocking Screws bring the knee into full extension and lay entire leg on sterile bumps move to distal tibia and get perfect circles of interlock screws ensure no rotation of the distal tibia is done while getting the fluoroscopic views (move the C-arm, not the leg) magnification of fluoro (x2) can be used if desired, but is not necessary use a 15 blade scalpel to locate the nailhole on medial distal tibia, and incise through skin spread down to bone with hemostat place drill in hole, then center drill parallel to xray beam drill toward center of C-arm beam do not stop drill when bit at nail unless progress halted by eccentric drilling if drilling is off, take drill off bit and leave bit in drilled hole recenter the bit on fluoroscopy and use a mallet to drive it across the nail holes measure the depth with a depth gauge or with calibrated drill bit remove drill quickly and insert screw repeat above process for 2nd distal interlocking screw have more freedom to move the limb for fluoroscopy after first screw placed Confirm Nail Position and Extremity Check obtain biplanar fluroscopic images of the proximal, middle, and distal tibia check limb length, rotation, alignment, and perform a knee ligamentous examination Closure Irrigation & Hemostasis strongly flush out reamings from knee with saline bulb irrigation irrigate until backflow is clear cauterize peripheral bleeding vessels Tissue Closure patellar tendon splitting close patellar tendon and paratenon layers with 0-Vicryl subcutaneous layered closure with 3-0 Vicryl skin closure with staples or suture medial parapatellar close parapatellar arthrotomy, subcutaneous and skin closure Dressing soft incision dressings over knee and distal tibia ACE wrap from distal thigh to toes to help with edema Postoperative Care Immediate Post-op weight-bearing as tolerated DVT prophylaxis immediate range of motion exercises to knee serial compartment checks x 24 hours 2-3 Weeks wound check staples/sutures removed continue physical therapy and range of motion exercises repeat radiographs of tibia Complications Most Common Complications post-operative knee pain symptomatic prominent interlocking screws malunion nonunion malrotation compartment syndrome superficial/deep infection