Tibial intramedullary nailing (suprapatella approach)- Synthes Expert Tibial Nail

A female patient in her twenties was unfortunately hit by a car, when she got out of a taxi. This caused an isolated injury to her left leg. She was haemodyamically stable, with no evidence of compartment syndrome and normal sensation to the deep peroneal, superficial peroneal, lateral sural, saphenous, medial and lateral plantar nerves. The posterior tibial and dorsalis pedis pulses were both present and had a normal volume.

There was a wound posteriorly on the calf, where the proximal tibia had punctured the skin (inside-out). It is worth remembering that an x-ray of a traumatic injury is like the last frame of a film reel, i.e. the leg was deformed to at least 90 degrees, for the proximal spike of the tibial fracture to be able to puncture the skin at the back of the calf.

For all lower limb surgery, where I’ll be using the C-arm, I prefer to use the carbon fibre table extension. I like this for 2 reasons:
It is completely radiolucent and nothing will obscure the radiographic image.
The table is completely smooth, so no transverse gaps in between sections, that things can fall into e.g. the nailing frame for holding and supporting the leg.

Pre-washing is an essential step when preparing the surgical site in trauma. The soapy water removes any obvious dirt and also dissolves any surface grease. Both water based and alcohol based antiseptics are immiscible liquids when combined with grease / oil. It therefore means that your surgical preparation can make more effective contact with the skin.

The contralateral leg has the pressure areas protected with a heel gel and a pneumatic thromboembolic deterrent device is applied.

My preference is to perform a double prep with two lots of alcoholic chlorhexidine. The first prep contains a dark pink dye. This allows me to confidently see that the whole limb has been coated in chlorhexidine. The second prep is with the same strength alcoholic chlorhexidine (0.5%) but it doesn’t have as much dye in. This therefore washes off the majority of the pink stain and due to the contrast in the solution colours, you can effectively see that the whole limb has been thoroughly painted twice. Ideally I would prefer not to use a pink stained solution, as sometimes it is mistaken for postoperative cellulitis!

The leg is draped for the first operation.

Before making any incisions, we discuss and plan our surgical strategy with the plastic surgeons. It’s slightly unusual for the wound to be posteriorly, as the soft tissues are thinner anteriorly and medially. We therefore agreed, that instead of extending the wound, we would stick to the principles of the BOA / BAPRAs guidelines and utilise an extensile fasciotomy incision to access and deliver the bone ends for debridement and washing.

The wound margins are traumatised skin. The skin has failed and ruptured under tension, it is therefore damaged, possibly contaminated and needs to be excised.
Using skin hooks in the apex, allows the skin to be tensioned and cut smoothly with a scalpel. I prefer not to use scissors, as I feel they crush the skin before they cut it.

The traumatic wound is then thoroughly irrigated.

An incision is made 1cm behind the posterior border of the tibia on the medial side. There are perforators that arise from the posterior tibial artery at 10cm and 15cm proximal to the medial malleolus. These should be avoided and preserved, as they can be used for local fasciocutaneous flaps. If only 1cm behind the posterior border of the tibia, the perforators will not be in your field, as these lie further back and do not need to be dissected out.

Blunt dissection is used to access the bone. Structures at risk include the saphenous vein and nerve. The posterior tibial artery and tibial nerve are also in this region. If trying to find them, they are easier to find distally and then trace proximally. Behind the medial malleolus the aide memoir / acronym, “Tom Dick and A Very Naughty Harry” will help you recall the order of the structures:
Tibialis Posterior tendon
Flexor Digitorum Longus
Posterior Tibial Artery
Posterior Tibial Vein
Tibial Nerve
Flexor Hallucis Longus tendon
Anterior to the medial malleolus is where the saphenous nerve and vein lie. The nerve is posterior in relation to the vein.

The leg is deformed to allow the bone end to be delivered. Note the saphenous vein that is crossing the inferior aspect of the wound (A). This incision gives access to the deep and superficial posterior compartments.

The bone ends are debrided with nibblers. Remember that these have been in contact with either the patient’s clothing or they have touched the road!

The traumatic channel is identified and carefully explored to ensure that no foreign material or dirt is hiding in the soft tissues.

The bone ends are now throughly washed with at least 6 litres of warmed sterile saline. The traumatic track is washed from inside-to-out, to flush any debris or contamination externally.

The wound is now clean. All ‘dirty’ instruments are removed. The drape is replaced with a fresh one and all surgeons change their gloves.

The traumatic wound is closed with a non-absorbable suture, as we don’t want to leave any foreign material in the wound, that could become contaminated / colonised.

In this case, the medial fasciotomy wound was left open, but now we have a complete set of new drapes and the surgeons have changed their sterile gowns and gloves. We are now starting a ‘new’ operation.
Surgical wounds are classified as:
Dirty / infected: infection present
Bowel perforation
Contaminated: significant contamination
Traumatic wounds (> 12-24 hours old)
Appendicectomy
Clean-contaminated: minimal contamination
Traumatic wounds (< 12-24 hours old)
Clean: no contamination
Elective surgery
We have therefore gone from a “contaminated” / “clean-contaminated” wound, to a “clean” wound.

To prevent the C-arm from de-sterilising the field when they swing the arm under the table for a lateral view, we stick an adhesive drape to the side of the table. If you count 3 creases from the free edge, this length of drape is approximately equivalent to the height of the operating table. We place 2 marks on the drapes (blue crosses A and B).

These are then clipped against the side of the operating table. This creates a sterile area between the crosses and the sticky edge attached to the table. Anything lateral to the crosses, is considered unsterile, as it is hanging vertically on the side of the operating table.

We are now ready to start the tibial nail. First I use the C-arm to mark out all of the relevant anatomy with a surgical marker.

The tibial plateau is marked, so that we know the plane of the joint. This helps when inserting the first STORM wire, so that it is parallel with the joint.

The anatomical axis of the tibia is marked. This helps when inserting the guide wire for the tibial nail, so that you are aiming in the direction of the centre of the diaphysis.

The “zone of injury to the bone” is marked – proximally.

and distally.

Finally the tibial plafond / ankle mortice are marked. This helps when inserting the calcaneal wire for STORM, so that it is parallel with the plafond and doesn’t apply any varus / valgus angulation when traction is applied.

This is the Staffordshire Orthopaedic Reduction Machine (STORM). It is specifically designed for tibial fracture management. The black and silver components are the STORM and the blue components are the STORM nailing extras. The STORM nailing extras have a radiolucent transverse bar, so that the view of the tibial plateau is not obscured by metal. The blue bit is also a kickstand that can be locked at various angles, to allow an infra-patella nailing technique.

An assistant lifts the leg and the STORM is placed under the limb.

The assistant holds the leg, so that the patella is facing forward. A 2mm fine wire is passed through the STORM device, anterior to fibula head but as far posteriorly as possible on the tibia (so that it doesn’t interfere with the tibial nail). It is passed so that it is parallel with the tibial plateau and exits on the medial side. Here it is passed through the STORM bracket, the wire is bent and cut short.

The 2mm wire is passed through the proximal tibia under image intensifier guidance. This wire is used to suspend the proximal tibia.

A second wire is passed through the STORM calcaneal wire frame and through the calcaneum. Care should be taken to ensure that the wire is parallel with the tibial plafond, so that any traction applies a balanced pull on the heel and doesn’t tip the hind foot into varus / valgus.
Both the proximal and distal fine wires are now tensioned (A) so that any forces applied by the STORM are directly transmitted to the bone.

The proximal large silver nut is allowed to freely spin (A). This allows the rotation of the distal fragment to be free at this stage.
The distal large silver nut (B) is turned clockwise to apply traction to the limb and distract the fracture fragments.

Under image intensifier guidance traction is applied to allow the fracture fragments to distract and “unlock”.
The rotation of the limb is then checked clinically. The patella should be facing forward and the tibial shaft should align with the second metatarsal. Radiologically because the tibia is triangular in cross-section, the thickness of the cortices above and below the fracture should match. Also the bone width should be equal, at the level of the fracture.

The fracture is externally manipulated to help correct any malalignment and then the traction is reduced to allow the fracture fragments to reduce and “key in”.
As the rotation has not been locked, the fracture can freely rotate as it reduces. This allows it to “autocorrect”. A final check of rotation is performed (clinical and radiological) and then the large proximal silver nut on STORM is locked.

The reduction is checked on the lateral view and any fine tuning is applied. If necessary, additional translation arms can be added to STORM to correct any angulation or translation of the fracture.

The knee is flexed and I prefer to use a wrapped set of sterile towels. This keeps them in one bundle and they are also radiolucent. By placing the proximal STORM brace on something, it causes the knee to flex. I’ve tried to use plastic kidney dishes but have found that they break. The number of towels can be increased or decreased to give the optimum amount of knee flexion.

An incision is made in line with the tibia’s anatomical axis that was previously marked. The incision is approximately 2-3cm in length and is 2-3cm proximal to the superior pole of the patella. Depending on the size of the leg, it might need to be more proximal or perhaps longer.
The initial incision is made through the skin and subcutaneous fat. Once down to the quadriceps tendon, a fresh blade is used but this time the incision is angled at 45 degrees and aims distally into the knee joint. This splits the quadriceps tendon longitudinally and gives access into the knee joint suprapatella pouch.
Once into the pouch, I use my finger to sweep through and feel the cartilage of the distal femoral trochlear. If there are any fibrous bands or plicae, these can be split with scissors using a blunt spreading technique.
With a finger in the patello-femoral joint, the assistant lifts the leg and slowly extends and flexes the knee. This is to find the optimum point that creates the largest tunnel under the patella and between the distal femur. The number of sterile towels supporting the STORM are then adjusted to maintain this position.

The protection sleeve is made up of a:
An outer plastic sleeve (not shown)
A metal inner sleeve
A plastic trochar (which is exchanged for the guide wire sleeve)
A handle

The plastic trochar has been removed by turning the black handle through 90 degrees. The guide wire sleeve has been inserted. The black handle should be turned back trough 90 degrees to lock and hold the sleeve and prevent it from backing out.
The guide wire sleeve allows wires to be placed both centrically and eccentrically. If the initial wire position is incorrect, then the sleeve can be rotated to place the eccentric wire in a better position (prior to eccentric wire insertion).

The protection sleeve for expert nail preparation consists of four components:
The outer (soft plastic) protection sleeve
The handle
The inner (hard metal) protection sleeve
The trochar
This is assembled and then the knob on the handle is rotated 90 degrees to lock the trochar in place. The protection sleeve assembly is then inserted into the knee.
If you are struggling to insert the assembly because the patello-femoral joint is too tight, then the longitudinal incision in the quadriceps tendon can be extended laterally and circumferentially around the patella to its’ mid-point. This should give an adequate release and allow the patella to translate anteriorly and increase the gap between the patella and the distal femur.

I insert the guide wire using a power tool, but first confirm the ideal entry point using the C-arm on both the AP and lateral views. With fine adjustment of the assembly, the guide wire can be angled to pass in line with the bone.
The trochar has 2 holes available for insertion of the 3.2mm guide wire – a central hole and an eccentric hole. If the initial wire placement needs to be improved, the internal trochar can be rotated like a clock face and a second wire inserted in a better position.

The suprapatella approach gives a better trajectory of alignment with the medullary cavity on the lateral view. Caution however is still needed so that the posterior cortex is not notched by the guide wire or opening drill. Once you are satisfied with your guide wire placement, the trochar can be removed (by turning the lock through 90 degrees).

I would encourage you not to pass the drill past the tip of the guide wire. If it does, then there is an increased chance of notching the posterior cortex. As you remove the drill, the guide wire usually comes out with it, but you need to keep pressure on the assembly handle to keep it in the trochlear and under the patella.
Alternatively an additional guide wire can be inserted through the handle to secure the protection sleeve assembly to the distal femur. However, this restricts its movement and can make it difficult when trying to remove the reamer (see later).

A 2.5mm ball nosed reaming rod is then inserted and passed distally across the fracture site. I would recommend inserting the wire by hand using a forward and backward technique to allow it to find a path down the medullary canal. I sometimes refer to this as “woodpecker technique”. Once past the fracture, the tactile feedback of the inner cortex of the bone is reassuring.
It is possible to use a mallet to encourage the ball nosed rod to go down, however, in osteoporotic bone, I worry that I may embedded it in the cortex or potentially perforate the bone.

The ball should sit and align with the middle of the talus on a mortice view of the ankle. It should not pass further than the physeal scar or risk perforating into the ankle joint.

After checking the ball position on a lateral as well, providing you’re satisfied with the placement, a mallet is then used to embed the ball into the subchondral bone, so that it is fixed and doesn’t move during reaming.

Now that the wire is in place and the bone is relatively well reduced, measure the length of the tibia, to determine the correct nail length. There are two methods:
Using the ruler that is provided on the set
Using a second ball nosed reaming rod, placing the ball at the opening into the tibia and then holding it parallel to the first rod and marking the excess rod with a haemostat. This excess length can then be measured with a ruler to determine the amount of the first rod, that is within the tibia.
Using the first method (the set ruler and the C-arm), place the tip of ruler at the level of the distal tibial physeal scar i.e. where the ball is. Check the position with the C-arm and mark the skin with marker pen (this is in case the ruler slips). Move the C-arm to the proximal tibia and take an x-ray. You may need to horizontally flip the image, to be able to read the ruler (as the numbers are back-to-front). Factor in the fracture reduction, and whether you’ll need to slap back the nail. Also consider that it is possible to lengthen the nail with end caps (0-15mm) but it is not possible to shorten the nail, if the wrong size is selected.
It is possible to measure the canal diameter however, I have found this to be inaccurate and prefer to determine the canal diameter when reaming.

The cannulated reamer is passed along the ball nosed rod all the way to the end of the rod. It’s helpful to take an x-ray and look at how much of the reamer shaft is still above the sleeve assembly. Using this information, you know how far you need to ream on each pass.
It is also important to check the fracture reduction as you pass the reamer, to ensure that the channel that you are creating is centric in both the proximal and distal fragments.

On withdrawing the reamer, you need to stabilise the ball nosed rod, to prevent it from backing out. In distal fractures, this is critically important or else you risk losing position and could end up reaming outside the distal fragment.
On the set, there is a “rod pusher” that can be used to pass through the power tool and keep axial pressure on the ball nosed rod.

Notice in this image that the power tool has been uncoupled from the reamer shaft. This makes it much easier to thread the cannulated reamer on to the reaming rod. Also when removing the reamer from the proximal tibia, the protection sleeve assembly needs to be manually tilted to allow the sleeve to align with the hole in the tibia. Commonly the reamer will get stuck on the edge of the sleeve and it won’t be possible to remove the reamer until this manoeuvre has been performed.
Once you are getting reasonable “chatter” from the diaphysis, it is recommend to deduct 1.5mm from the last reamer size, to determine the nail diameter.

The nail is connected to the insertion handle with a connecting screw. There is a notch in the nail to prevent the nail being connected incorrectly. The radiolucent aiming arm is connected and the protection sleeve, drill sleeve and trochar are inserted through the respective hole in the jig. The trochar is removed and the appropriate size drill is passed through the drill sleeve and should pass concentrically through the hole in the nail. If it doesn’t, then you need to repeat all of the steps to identify where the problem lies.
Once you are satisfied that the aiming arm correctly aligns with the holes in the nail, then it is removed, leaving only the insertion handle. A striking plate is connected, as direct blows to the insertion handle could deform it and prevent it from correctly aligning with the nail holes.

Prior to nail insertion, the inner metal protection sleeve must be removed. This leaves the outer plastic sleeve connected to the handle (not shown in this image).
To remove the inner metal protection sleeve, you must depress both levers on the front and rear of the handle. This lifts a metal plug out of the hole on the side of the inner metal protection sleeve (see the next slide).

To remove the inner metal protection sleeve, both A & B must be pressed simultaneously. This removes the 2 metal plugs (C) from the holes (D) in the metal protection sleeve.

When inserting nails with a diameter of 8mm – 11mm, then the 12mm outer plastic protection sleeve should be used.
When inserting nails with a diameter of 12mm – 13mm, then the 14.5mm outer plastic protection sleeve should be used.
The plastic protection sleeve has been removed from the image to demonstrate the notches on the under surface of the handle (A). The sleeve/handle is rotated through 90 degrees (anticlockwise to unlock, clockwise to lock).

Prior to nail insertion, the inner (metal) protection sleeve must be removed from the protection sleeve assembly (this is easy to forget to do). If using an Expert Tibial Nail that is greater than 12mm in diameter, then the outer (plastic) protection sleeve must be changed, as a larger diameter nail will not fit through it.
The nail is inserted and because it is not a straight nail, I prefer not to use a twisting action and recommend using controlled blows with the mallet to gently advance the nail.

It is helpful if your assistant holds the ball nosed reaming rod. This prevents it from backing out, which can sometimes be a problem in low distal fractures. It also stops the rod from wobbling with each mallet strike and potentially de-sterilising itself or hitting someone.

Carefully advance the nail across the fracture, all the while checking the reduction and alignment. As you approach the final 2-3cm, I would recommend pulling the ball nosed reaming rod out, as sometimes this gets lodged in the subchondral bone and the rod can bend. This then makes it difficult to remove through the nail. It is also important to keep an eye on the fracture, to ensure that the fracture is not distracting and the nail is advancing.

Depending on the fracture configuration, this will determine whether the nail is locked either proximally or distally first. In this case, I wanted to lock distally first, so that the nail could be “knocked back” to reduce the fracture gap.
It is personal preference whether a ring is held over the distal locking hole or whether you go straight for the knife. Personally I find the knife a little bit more accurate and this means that the soft tissues are not pulling against the drill.

When aligning the C-arm with the holes to make them round, there are some keys steps. Firstly, try and let your radiographer do it by themselves. Some experienced radiographers need no further instructions. For those that do, the following sequence of steps will help:
Align the base of the C-arm machine with the leg, so that it is parallel.
Obtain an image with the target hole in the very centre.
Some machines allow a magnified image.
Move the C-arm so that there is enough room to get the drill / screwdriver in between the C-arm and leg.
If the hole is elliptical in shape, then the angle of the C-arm needs to change.
In this example, if the hole is narrow top-to-bottom (anterior-to-posterior), then the C-arm needs to rotate under the operating table to correct it.
In this example, if the hole is narrow side-to-side (proximal-to-distal), then the C-arm needs to change its’ horizontal alignment to correct it.
Finally lock all of the brakes and take one last image to confirm a perfectly round hole.

Stab incisions with the scalpel that go down to the bone should be avoided, as it is possible to inadvertently injure the saphenous vein. Bleeding from the saphenous vein is often harder to control than anticipated and will need the wound to be extended.
The scalpel is used to cut the skin and deep dermis only. Either an artery clip or a pair of scissors is used to perforate the soft tissues beneath and scrape the soft tissues off the bone. The instrument is then opened and withdrawn, to create a single channel and the soft tissues are displaced safely away from the drill bit.

The blue nails (8-9mm diameter) use a 3.2mm drill bit and 4mm locking bolts.
The green nails (10-13mm diameter) use a 4.2mm drill bit and 5mm locking bolts.
The drill is inserted into the wound and it is easier to hold the power tool with one hand and use the contralateral hand to make fine adjustments to the drill bit position. Once satisfied that the drill tip is sitting concentrically within the locking bolt hole, the drill angle is changed to match the angle of the x-ray beam.

After drilling the near cortex, through the nail hole and then the far cortex, I would recommend uncoupling the drill bit from the drill to radiographically confirm that the drill bit is passing through the nail and not sitting either in front or behind the nail.
If you are unsure, a Kocher can be used to gently pull the drill bit, so that it aligns with the nail.

The locking bolt length is measured.

The locking bolt is inserted but during the final few turns, it is worth sweeping around the head of the bolt with a pair of forceps, to ensure that no soft tissues are going to be tethered.

When inserting locking bolts from anterior-to-posterior, due to the presence of the anterior tibial artery and deep peroneal nerve, I would encourage you to make a small approach, so that the locking bolt can be inserted under direct vision.

The nail is knocked back using the slap hammer to close the fracture gap. Prior to doing this, any traction that has been applied by STORM must be released.

The reduction is checked radiographically and the alignment has been maintained.

The proximal locking bolts are inserted using the jig. However, it is worth checking that the connecting screw that connects the jig to the nail, is still tight, as sometimes it can loosen.

Careful attention needs to be given to the proximal screws, as although they are covered with muscle, they often cause some irritation to the patients.

Once the nail is locked both proximally and distally, the STORM can be removed.
The nail-jig connecting screw is often very tight and by gently flexing / extending the knee, the amount of force required to remove the screw is decreased.

Final images are taken and saved. There is a debate about whether to use an end cap. I personally have not had too much trouble removing nails however, if they are particularly short, then I would use an end cap to build up the nail length, so that it is not deep within the bone.
I have seen, on more than one occasion, an end cap in the proximal tibia and this has taken some considerable time to remove (despite using a guide wire into the top of the nail).

The knee joint is washed out to remove the reamings / bone swarf.

In this case, we decided to leave the fasciotomy open during the procedure, in case the patient developed compartment syndrome. If they had, then it could easily be extended proximally and distally. We were satisfied that there was no compartment syndrome, so the wound was irrigated and closed.

To repair the quadriceps tendon through a small incision, we use a vicryl suture on a J shaped needle. The other wounds can be closed with either an absorbable or non-absorbable suture (except the traumatic wound, which is closed with a non-absorbable suture).

The leg is bandaged in two separate areas. This leaves the mid-portion exposed. If the patient complains of significant pain, then it is easy to access the leg and assess the compartments without having to remove all of the bandages.
If, after assessment, you suspect a compartment syndrome, then the circumferential bandages must be released.

The post-operative radiograph demonstrates that the ankle joint is within 5 degrees of the anatomical axis of the tibia.

The post-operative radiograph demonstrates that the fracture has shortened slightly due to the obliquity of the fracture. It is however less than 15mm and the joint angle is within 10 degrees of the normal joint angle (80 degrees anterior)