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Name:
Suprapatellar Nailing
Description:
Suprapatellar Nailing
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/89b8f64a-9fff-4e7c-9617-ae0a32f31118/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H09M34S
Embed URL:
https://stream.cadmore.media/player/89b8f64a-9fff-4e7c-9617-ae0a32f31118
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/89b8f64a-9fff-4e7c-9617-ae0a32f31118/Suprapatellar nailing.mp4?sv=2019-02-02&sr=c&sig=7yGO3YIuttrBRTr9bo2o5ShQftg99rvgsRqOwt5tvFE%3D&st=2024-11-23T12%3A01%3A43Z&se=2024-11-23T14%3A06%3A43Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ASHOK GAVASKAR: Good afternoon. This is Dr. Gavaskar, and I would like to share some tips and tricks with regards to Suprapatellar Tibial Nailing. If you look at the conventional approaches for doing a tibial shaft nailing, you can either do it in flexion using the infrapatellar approach, or you can do it with the knee in extension by using the parapatellar or the suprapatellar approaches.
ASHOK GAVASKAR: Personally, I believe doing it in extension has a lot of advantages. First thing is you have tremendous control over the entire limb since it is in supine on a radiolucent table. And you have great access to fluoroscopy without any hindrance. And if you want to do some reduction maneuvers, like clamping a fracture or even applying an external fixator or a distractor to get the fracture out to length, you can do it much more easily compared to what you can with the knee inflection.
ASHOK GAVASKAR: So if you look at the incidences of malalignment reported after tibial shaft nailing, and if you consider studies beyond, before 2000, you can look at the amount of malalignment is much higher and it is definitely the case when you consider metadiaphyseal fractures compared to shaft fractures. But if you look at studies over the last decade or so, you can definitely notice there is a significant drop in the incidences of malalignment.
ASHOK GAVASKAR: Part of this can definitely be attributed to doing more and more of these nailings in a semi extended position compared to doing it in knee flexion. So suprapatellar nailing is one such technique where you do it in a semi extended position. So if you want to successfully do a supra patellar nailing, you need to focus on a few things. One is, you know that the patellofemoral joint is vulnerable to damage during the technique and you need to know techniques to avoid it.
ASHOK GAVASKAR: You have to focus on getting your right entry point and also the right trajectory. And you also have to look at techniques to reduce and hold the fracture during the process of nailing. It is highly important that you start well. Entry point is always the key, especially when it comes to metaphyseal practice. The entry point usually lies over the medial aspect of the lateral tibial spine in the coronal plane and starts just at the tip of the joint cavity outside it actually.
ASHOK GAVASKAR: And in line with that tibial intramedullary cavity, the sag plane and the tibial entry point doesn't change regardless of the technique. The entry point remains the same whether your fracture is located proximally mid shaft or distally and you need to stick onto it if you want to get good outcomes. But there are challenges in getting a good entry point, even with the Supra patella technique. So it is important to plan well ahead.
ASHOK GAVASKAR: This is how a limb will look like when you are positioning it for a supra patellar nailing.
ASHOK GAVASKAR: Make sure you put a bump under the hip, which will minimize external rotation and it is important to get a good start point. Limber rotation is important. If you look at the images on the right, you can see that the entry point in the first image looks pretty bad because it's more median, but it is not the case. If you look at the fibula, you can see it is completely uncovered, indicating the limb is in a lot of internal rotation and once you get into the neutral rotation, you can see that the entry point is not really bad.
ASHOK GAVASKAR: So you have to understand that rotation can influence your entry point significantly and it is important to keep your limb in the right rotation when you get your entry point to nail this. It is also important to get proper imaging if you want to nail metadiaphysis fractures of the tibial shaft. So it is important to keep the C arm on the opposite side, keep the other limb away from any hindrance, centre your patella
ASHOK GAVASKAR: and if you are going to rely on the lateral tibial spine to get your entry point on the AP view, you have to look for the tibial lateral tibia bisecting the fibula end. This indicates the proper AP view, and once you've got it, you can rely on that to get your entry point and the subsequent trajectory. So how to get access to the entry point through the Supra patellar technique.
ASHOK GAVASKAR: Hyperextension definitely helps, it loosens the patellofemoral compartment and you can get access to it easily. And if you still don't get good access with hyperextension, sometimes it might happen, don't hesitate to extend it into a lateral patellar arthroscopy. And when you take an entry point, do not use the sleve, use it free, and making sure you protect the PF joint all the time.
ASHOK GAVASKAR: You don't allow the sleeve to bias your entry point and once you've got your guidewire in a little bit inside the tibial cavity, you can then do everything under the protection sleeve. So finding the right entry point alone is not enough, the subsequent trajectory is important too. When you take your entry point, you almost always are on the lateral aspect of the tibia and the soft lateral tibial bone can make the guidewire and the subsequent reamers fall onto the lateral side.
ASHOK GAVASKAR: So it is important to be cognizant of this fact and make sure your guidewire reamer everything is centered in line with the tibial shaft all the time. Some of the common mistakes that you need to avoid with regards to the technique is don't try to start too wide, you risk articular injury, especially into the meniscal ligament and also the femoral trochlea will never allow you to get that right trajectory.
ASHOK GAVASKAR: Another thing that to avoid is reamer creep. Even though you start as high as possible, as you can see on the image, sometimes with subsequent reaming you can ream out that anterior bone so that you, your reamer falls more distally and anteriorly so you might end up something like that. So it is important to avoid eroding this bone because it helps you to keep the nail contained and minimize soft tissue impingement.
ASHOK GAVASKAR: So whenever you take your reamer out, make sure you do it by hand and not on power as you reach this point so that you can preserve the anteriorial bone. In order to get the right trajectory, you cannot keep the ligament law of extension. You need a little bit of flexion to get in line with the intramedullary cavity. Around 40 degree of flexion is needed and once you've got in line with the intramedullary cavity and then you can bring the limb into a semi extended position and do the rest of the procedure.
ASHOK GAVASKAR: So it is important to get in line with the intramedullary cavity, otherwise our femoral trochlea will keep fighting you and you may be pushed too anteriorly. It is important to appreciate problematic fracture patterns, patterns where trajectory becomes so important, so appreciate fractures which have large anterior spikes which can deform and also fractures with lateral commination and posterior comminution too.
ASHOK GAVASKAR: So, and if you think your fracture can deform during entry, it is better you reduce and hold them by some means. And if they deform during the nailing, then blocking screws really come in handy. So these are some of the fracture patterns that you will know that they will deform even before you start the procedure. So it is important to kind of clamp or even plate some fractures and then start your nailing procedure.
ASHOK GAVASKAR: So you have a reduction before you start your nail enclosure, per se. Some of the other options to hold include an external fixator or a distractor, especially if you want to bring them to length and you can use plates as well. And if they do reform during nailing, then blocking screws can effectively reduce the metaphyseal space and can act as artificial cortexes,
ASHOK GAVASKAR: keeping your nail where you want it to be. You can either screw your screws or wires, depending on location, which is highly variable. And if you're going to use wires, make sure you use a high caliber wire, more than 2.5 millimeter in diameter, and make sure you hold the Kocher clamp so that it doesn't migrate when the reamer gets in contact with it. If you're going to use wires, it gives you the flexibility of removing and replacing it, and you can also cascade it,
ASHOK GAVASKAR: if you're going to use it, use a lot of wires And with the supra patellar technique, it is possible to leave the nail as high as possible because you start quite high and this could be especially useful in proximal metaphyses and fractures because you can get all your screws in so that you get a much higher degree of purchase. And once you've done the procedure, flush the knee of all debris and also inspect the femoral cut trochlea and the patellofemoral joint for any possible cartilage damage.
ASHOK GAVASKAR: So summarize. Supra patellar nailing helps you achieve excellent union rates. There are concerns about patellarfemoral articulation, but the current evidence does show that it is relatively safe to perform this procedure without any long term problems. There is a possibility of injury to internal intra articular structures if your technique is not right. There is a small consensus of small concerns of knee sepsis, which is possible.
ASHOK GAVASKAR: But of course, there are no good quality studies to suggest that supra patellar nailing has a higher incidence of infection compared to infra patellar nailing. Thank you.
Segment:0 .
ASHOK GAVASKAR: Good afternoon. This is Dr. Gavaskar, and I would like to share some tips and tricks with regards to Suprapatellar Tibial Nailing. If you look at the conventional approaches for doing a tibial shaft nailing, you can either do it in flexion using the infrapatellar approach, or you can do it with the knee in extension by using the parapatellar or the suprapatellar approaches.
ASHOK GAVASKAR: Personally, I believe doing it in extension has a lot of advantages. First thing is you have tremendous control over the entire limb since it is in supine on a radiolucent table. And you have great access to fluoroscopy without any hindrance. And if you want to do some reduction maneuvers, like clamping a fracture or even applying an external fixator or a distractor to get the fracture out to length, you can do it much more easily compared to what you can with the knee inflection.
ASHOK GAVASKAR: So if you look at the incidences of malalignment reported after tibial shaft nailing, and if you consider studies beyond, before 2000, you can look at the amount of malalignment is much higher and it is definitely the case when you consider metadiaphyseal fractures compared to shaft fractures. But if you look at studies over the last decade or so, you can definitely notice there is a significant drop in the incidences of malalignment.
ASHOK GAVASKAR: Part of this can definitely be attributed to doing more and more of these nailings in a semi extended position compared to doing it in knee flexion. So suprapatellar nailing is one such technique where you do it in a semi extended position. So if you want to successfully do a supra patellar nailing, you need to focus on a few things. One is, you know that the patellofemoral joint is vulnerable to damage during the technique and you need to know techniques to avoid it.
ASHOK GAVASKAR: You have to focus on getting your right entry point and also the right trajectory. And you also have to look at techniques to reduce and hold the fracture during the process of nailing. It is highly important that you start well. Entry point is always the key, especially when it comes to metaphyseal practice. The entry point usually lies over the medial aspect of the lateral tibial spine in the coronal plane and starts just at the tip of the joint cavity outside it actually.
ASHOK GAVASKAR: And in line with that tibial intramedullary cavity, the sag plane and the tibial entry point doesn't change regardless of the technique. The entry point remains the same whether your fracture is located proximally mid shaft or distally and you need to stick onto it if you want to get good outcomes. But there are challenges in getting a good entry point, even with the Supra patella technique. So it is important to plan well ahead.
ASHOK GAVASKAR: This is how a limb will look like when you are positioning it for a supra patellar nailing.
ASHOK GAVASKAR: Make sure you put a bump under the hip, which will minimize external rotation and it is important to get a good start point. Limber rotation is important. If you look at the images on the right, you can see that the entry point in the first image looks pretty bad because it's more median, but it is not the case. If you look at the fibula, you can see it is completely uncovered, indicating the limb is in a lot of internal rotation and once you get into the neutral rotation, you can see that the entry point is not really bad.
ASHOK GAVASKAR: So you have to understand that rotation can influence your entry point significantly and it is important to keep your limb in the right rotation when you get your entry point to nail this. It is also important to get proper imaging if you want to nail metadiaphysis fractures of the tibial shaft. So it is important to keep the C arm on the opposite side, keep the other limb away from any hindrance, centre your patella
ASHOK GAVASKAR: and if you are going to rely on the lateral tibial spine to get your entry point on the AP view, you have to look for the tibial lateral tibia bisecting the fibula end. This indicates the proper AP view, and once you've got it, you can rely on that to get your entry point and the subsequent trajectory. So how to get access to the entry point through the Supra patellar technique.
ASHOK GAVASKAR: Hyperextension definitely helps, it loosens the patellofemoral compartment and you can get access to it easily. And if you still don't get good access with hyperextension, sometimes it might happen, don't hesitate to extend it into a lateral patellar arthroscopy. And when you take an entry point, do not use the sleve, use it free, and making sure you protect the PF joint all the time.
ASHOK GAVASKAR: You don't allow the sleeve to bias your entry point and once you've got your guidewire in a little bit inside the tibial cavity, you can then do everything under the protection sleeve. So finding the right entry point alone is not enough, the subsequent trajectory is important too. When you take your entry point, you almost always are on the lateral aspect of the tibia and the soft lateral tibial bone can make the guidewire and the subsequent reamers fall onto the lateral side.
ASHOK GAVASKAR: So it is important to be cognizant of this fact and make sure your guidewire reamer everything is centered in line with the tibial shaft all the time. Some of the common mistakes that you need to avoid with regards to the technique is don't try to start too wide, you risk articular injury, especially into the meniscal ligament and also the femoral trochlea will never allow you to get that right trajectory.
ASHOK GAVASKAR: Another thing that to avoid is reamer creep. Even though you start as high as possible, as you can see on the image, sometimes with subsequent reaming you can ream out that anterior bone so that you, your reamer falls more distally and anteriorly so you might end up something like that. So it is important to avoid eroding this bone because it helps you to keep the nail contained and minimize soft tissue impingement.
ASHOK GAVASKAR: So whenever you take your reamer out, make sure you do it by hand and not on power as you reach this point so that you can preserve the anteriorial bone. In order to get the right trajectory, you cannot keep the ligament law of extension. You need a little bit of flexion to get in line with the intramedullary cavity. Around 40 degree of flexion is needed and once you've got in line with the intramedullary cavity and then you can bring the limb into a semi extended position and do the rest of the procedure.
ASHOK GAVASKAR: So it is important to get in line with the intramedullary cavity, otherwise our femoral trochlea will keep fighting you and you may be pushed too anteriorly. It is important to appreciate problematic fracture patterns, patterns where trajectory becomes so important, so appreciate fractures which have large anterior spikes which can deform and also fractures with lateral commination and posterior comminution too.
ASHOK GAVASKAR: So, and if you think your fracture can deform during entry, it is better you reduce and hold them by some means. And if they deform during the nailing, then blocking screws really come in handy. So these are some of the fracture patterns that you will know that they will deform even before you start the procedure. So it is important to kind of clamp or even plate some fractures and then start your nailing procedure.
ASHOK GAVASKAR: So you have a reduction before you start your nail enclosure, per se. Some of the other options to hold include an external fixator or a distractor, especially if you want to bring them to length and you can use plates as well. And if they do reform during nailing, then blocking screws can effectively reduce the metaphyseal space and can act as artificial cortexes,
ASHOK GAVASKAR: keeping your nail where you want it to be. You can either screw your screws or wires, depending on location, which is highly variable. And if you're going to use wires, make sure you use a high caliber wire, more than 2.5 millimeter in diameter, and make sure you hold the Kocher clamp so that it doesn't migrate when the reamer gets in contact with it. If you're going to use wires, it gives you the flexibility of removing and replacing it, and you can also cascade it,
ASHOK GAVASKAR: if you're going to use it, use a lot of wires And with the supra patellar technique, it is possible to leave the nail as high as possible because you start quite high and this could be especially useful in proximal metaphyses and fractures because you can get all your screws in so that you get a much higher degree of purchase. And once you've done the procedure, flush the knee of all debris and also inspect the femoral cut trochlea and the patellofemoral joint for any possible cartilage damage.
ASHOK GAVASKAR: So summarize. Supra patellar nailing helps you achieve excellent union rates. There are concerns about patellarfemoral articulation, but the current evidence does show that it is relatively safe to perform this procedure without any long term problems. There is a possibility of injury to internal intra articular structures if your technique is not right. There is a small consensus of small concerns of knee sepsis, which is possible.
ASHOK GAVASKAR: But of course, there are no good quality studies to suggest that supra patellar nailing has a higher incidence of infection compared to infra patellar nailing. Thank you.
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