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Selected

Instructional
Course Lectures
The American Academy of Orthopaedic Surgeons
P AUL T ORNETTA III
EDITOR, VOL. 61

C OMMITTEE
P AUL T ORNETTA III
CHAIR

K ENNETH A. E GOL
M ARY I. OC ONNOR
M ARK P AGNANO
R OBERT A. H ART
E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES

Printed with permission of the American Academy of

Orthopaedic Surgeons. This article, as well as other lectures
presented at the Academys Annual Meeting, will be available
in February 2012 in Instructional Course Lectures, Volume 61.
The complete volume can be ordered online at www.aaos.org,
or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).

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Surgical Techniques for Complex

Proximal Tibial Fractures
Jason A. Lowe, MD, Nirmal Tejwani, MD, Brad Yoo, MD, and Philip Wolinsky, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Traditional and Alternative Surgical

Approaches to the Tibial Plateau:
How to Select Them?
Any surgical approach for fracture fixation should facilitate visualization of
fracture fragments and allow the application of optimal fixation devices and
soft-tissue repair. Treatment goals applied to tibial plateau fractures include
anatomic articular surface reduction,
restoration of the anatomic axis, and
preservation of the menisci. The approach should not devitalize soft tissues
or cause further injury to surrounding
structures. An ideal surgical dissection
encompasses these principles and permits early joint motion.
The midline longitudinal incision
is the favored approach to the knee joint,
as this incision facilitates knee replacement if needed in the future. Surgical
exposure for complex injuries (bicondylar fractures) requiring dual fixation
needs large medial and lateral flaps that
add to soft-tissue complications. Other
surgical approaches allowing a more
direct approach to the fracture to decrease the risk of soft-tissue injury from

excessive retraction or periosteal stripping are available. When one incision

does not adequately expose the fracture,
it is better to use a dual incision than a
single midline exposure1-3.
Anterolateral Approach
The anterolateral approach is used for
the most commonly seen tibial plateau
fractures (Schatzker4 types I, II, and
III). It is also used for the lateral part of
a dual incision approach needed for
internal fixation of a bicolumnar fracture. The incision is centered on
Gerdys tubercle and is shaped as a
lazy S or a hockey stick. The fascia is
elevated off the tibial tubercle to expose
the lateral tibial plateau. The knee
capsule is incised, and a submeniscal
arthrotomy allows visualization of the
articular surface (Figs. 1 and 2). In
addition to visualization of the articular
surface, this approach allows repair of
any meniscal tears.
Medial Approach
The medial approach is used for a
medial tibial plateau fracture (Schatzker

type IV) or as part of a dual approach to

the plateau. The incision parallels the
posteromedial border of the proximal
part of the tibia. The pes anserinus is
elevated, the fracture reduced, and
fixation implants are placed beneath
the pes anserinus. The pes anserinus
may either be retracted (Fig. 3) or
incised, with repair after fracture fixation. The medial meniscus cannot be
elevated as is possible with the lateral
meniscus; therefore, the limitation of
this approach is the limited visualization of the articular surface of the
medial plateau. Also, access to the posterior plateau is limited, but the medial
approach can be converted to a posteromedial approach.
Anterior Approach with Tibial Tubercle
Osteotomy
The advantage of the anterior approach
with osteotomy of the tibial tubercle is
that the tibial plateau and the intercondylar notch are completely exposed,
allowing reattachment or primary suture of the cruciate ligaments5. This
approach is rarely used, and most

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any
aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this
work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has
had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in
this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2011;93:1548-59

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cle and the semitendinosus muscle

allows exposure of the semimembranosus muscle, which is detached for
better access to the posterior aspect of
the tibia. Visualization of the articular
surface is limited, but, if necessary,
visualization can be improved with a
longitudinal split in the medial collateral ligament and capsule. Through this
incision, visualization of the articular
cartilage can aid in congruent joint
reduction.

Fig. 1

Clinical photograph of a patients right knee with the lazy-S incision used for internal fixation of a lateral
proximal tibial fracture.

complex, bicondylar fractures are now

treated with use of dual incisions.
Posteromedial Approach
Medial tibial plateau fractures extending to the posterior aspect of the tibial
plateau, posterior metaphyseal fractures, or those that require a buttress
on the posteromedial cortex are best
fixed with use of the posteromedial
approach. Fragment-specific fixation
of the medial plateau is recommended
over stabilization with a laterally based
locking construct6. To obtain optimal

fixation of bicondylar fractures, a dual

plating technique is recommended,
with one plate fixing the medial fragment and one fixing the lateral plateau.
Medial plateau fractures may be medial or posteromedial, with each requiring a plate to be, ideally, placed at
the apex of the fracture (fragmentspecific).
The patient can be positioned
prone or supine7. An incision is made
over the posteromedial aspect of the
knee (Fig. 4). Dissection between the
medial head of the gastrocnemius mus-

Fig. 2

Clinical photograph of a patients right knee with retention sutures in the lateral meniscus (white
arrow) of a submeniscal arthrotomy.

Posterior Approach
An isolated posterior shear fracture, a
posterior cruciate ligament avulsion
fracture with a large osseous fragment,
or a posterior fracture dislocation is best
exposed with a posterior approach8,9. A
z-shaped incision across the flexor
crease is used. The deep tissue planes are
between the medial head of the gastrocnemius and the semimembranosus
muscles or between the two heads of the
gastrocnemius muscle with protection
of the neurovascular structures. The
medial or lateral head of the gastrocnemius muscle may be partially detached,
if it is necessary to improve exposure,
enable fracture reduction, or insert
fixation on the posterior rim.
Extended Lateral Approach with
Fibular Osteotomy
The Lobenhoffer approach is used to
expose fractures of the lateral tibial
plateau that extend posteriorly when the
head of the fibula limits the exposure10,11.
The skin incision is made along
the course of the peroneal nerve, posterior to the fibular head. After dissection, the common peroneal nerve is
protected and an osteotomy of the fibula
at the junction of the head and neck is
performed, leaving the proximal attachments intact. This allows exposure
of the tibial plateau from anterior to
posterior.
Another way to approach the
posterolateral plateau is without a fibular osteotomy10. Absence of an osteotomy makes it more difficult to visualize
the tibial fracture at the level of the
fibular head; however, this approach
is preferred as it avoids the risk of a
nonunion at the fibular osteotomy site.

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the medial aspect of the joint. Anatomic reduction is confirmed by

aligning the articular cartilage of each
fragment while the cortex is reduced
with a well-placed Weber clamp perpendicular to the fracture. This whitewhite read of the medial plateau
articular cartilage augments accuracy
of reduction.

Fig. 3

Clinical photograph of a patients left knee with a medial incision (patients head is to the left). The
tendons of the pes anserinus (white arrow) are seen over the clamp.

Medial Tibial Plateau Reduction

A shearing force produces a coronal
plane fracture comprising approximately 25% of the medial articular
surface12. This fragment is seen on a
lateral radiograph, but the full extent of
articular involvement is best appreciated on sagittal computed tomography
(CT) images. Since the medial collat-

eral ligament (MCL) prevents a submeniscal arthrotomy, reduction of the

medial joint line is often obtained
indirectly with anatomic restoration of
the medial cortex. If there is a question
about the accuracy of the reduction of
the articular surface of the medial
plateau, a longitudinal incision is made
in the MCL, where the fracture enters

Fig. 4

Clinical photograph of a patients right knee. With the patient in the prone position, the solid line
identifies the level of the knee joint with the femur to the left. The dashed line illustrates an incision for
a posterior-medial incision.

Medial Plateau Fixation

Surgical stabilization of isolated medial plateau fractures (Schatzker type
IV) is accomplished with an undercontoured, nonlocking, flexible plate
(1/3 T-plate or reconstruction plate)
applied as a buttress. Fixation of the
medial plateau in Schatzker type-V and
VI fractures is more controversial.
Stabilization can be accomplished with
locking screws placed through a laterally based implant alone or stabilized
with a medial plate as part of a dual
plating construct (medial and lateral
plate)13-17. Biomechanical and clinical
data support both techniques. Although lateral-only locked plates reduce surgical time, blood loss, and
limit soft-tissue stripping, a high rate
of articular subsistence (26%) has been
reported13-17. Displacement of the medial fragment can result in knee instability, pain, and posttraumatic
osteoarthritis12. The authors, therefore, recommend fragment-specific
fixation of the posteromedial and lateral plateau through a two-incision
approach for bicondylar tibial plateau
fractures. Fragment-specific fixation of
the medial plateau avoids inadequate
purchase of the posteromedial fragment observed with lateral-only locking screws6,16-18. The benefit of added
fracture stability is offset by greater
surgical time and higher postoperative
infection rates. Current reports have
demonstrated postoperative infection
rates of 8.4% with dual plating compared with 1.6% with lateral-only
fixation13,14. In the absence of a prospective, randomized, controlled trial
comparing these surgical approaches,
the need for anatomic reduction of the
joint surface and adequate stabilization of the medial plateau takes
precedence.

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Fig. 5

Clinical intraoperative photograph of a patients left knee, demonstrating incisions for minimally

to 1/2 in (0.64 to 1.3-cm) osteotome

or bone tamp is used to elevate 1.0 to
1.5 cm of cancellous bone with the articular segment. Once levered into position, the fragment is stabilized with
Kirschner wires. With the impacted
segment reduced and secured with wire
fixation, bone voids can be filled with
graft material and the lateral segment
can be reduced (closing the door). The
medial and lateral plateaus can be reduced and compressed with a periarticular reduction clamp19.
The contained defect of a pure
depression fracture cannot be reduced
without an osteotomy. If there is an
incomplete fracture, the articular segment is accessed by completing the
fracture and reducing the articular
fragment as described above. If there is
no cortical fracture, articular reduction
is done with one of two techniques. The

invasive plate osteosynthesis.

Lateral Plateau Articular Reduction

High-energy bicondylar tibial fractures
are typically associated with articular
surface impaction of the lateral plateau.
Successful restoration of the lateral
aspect of the joint requires adequate
visualization and an array of reduction
techniques. A submeniscal arthrotomy
and a laterally based femoral distractor
improve visualization of the articular
surface when needed. A single Schanz
pin is placed into the femoral metaphysis, parallel to the joint line, and a
second Schanz pin is placed in the tibia,
distal to planned plate placement location19. Care must be used with
placement of a lateral tibial pin so as to
not injure the neurovascular structures of the anterior compartment20.
Applying distraction opens the joint
and enhances visualization of the lateral plateau. Retraction of the posterolateral or anterolateral fragments
(opening the door) can allow even
more visualization.
Mobile articular pieces are reduced with a dental pick or a small (0.45
to 0.62-mm) wire and are temporarily
stabilized with Kirschner wires. Impacted articular fragments must be
mobilized from surrounding cancellous
bone before they can be reduced. A 1/4

Fig. 6

Anteroposterior radiograph of a knee

illustrating the inability of locking
screws to reduce the valgus malalignment in the coronal plane. As a result, a
valgus malunion, with the plate poorly
apposed to the tibia, is observed.

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Fig. 7

Fig. 7 Anteroposterior and lateral

radiographs of an extra-articular
proximal tibial fracture demonstrating the most common deformities (valgus and procurvatum)
observed in these fractures. Fig. 8
Anteroposterior radiographs
showing how a medial starting
site produces a valgus deformity
as the intramedullary device enters the tibial diaphysis.

Fig. 8

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anterior compartment is released from

the metaphyseal flare for both. One
technique is to use the DHS (Dynamic
Hip Screw; Synthes, Paoli, Pennsylvania)
set and fluoroscopic visualization. The
guidewire is directed from the lateral
tibial metaphysis toward the impacted
segment. The cortex is then opened with
the cannulated 11-mm reamer from the
DHS system. Bone tamps are introduced
and used to tap the articular segment
into place. The articular reduction is
confirmed by direct visualization
through the submeniscal arthrotomy.
Alternatively, a lateral osteotomy is
made with drill holes (2.0-mm drillbit) in a diamond pattern, with the
drill holes connected with use of a
0.25-in (0.64-cm) osteotome. The
articular segment is reduced as just
described. With either technique, the
articular fragments can be supported
with Kirschner wires and bone graft
prior to definitive fixation.
Lateral Plateau Fixation
Surgical stabilization of the lateral
plateau must maintain reduction and
rigid fixation of the articular segment
to a well-aligned tibial shaft. The joint
surface is stabilized with multiple
parallel screws placed just beneath
the subchondral bone. These rafting
screws support the reduced articular
surface fragments and can be the proximal screws of a 3.5-mm or a 4.5-mm,
precontoured periarticular plate or with
minifragment (2.4 or 2.7-mm) screws.
Minifragment screws and plates are
favored for articular comminution
with fragments having minimal subchondral bone or when the proximal
screws in the precontoured plate are
not subchondral.
The articular segment is reduced
to the shaft with traction (a manual or
femoral distractor). First, the plate is
fixed to the proximal segment with
bicortical screws (locked or nonlocked)
inserted parallel to the joint21. The plate
is reduced to the tibial shaft with a
bicortical screw or a so-called whirlybird
push-pull type of device. It is important
to ensure that this does not malreduce
the fracture in the coronal plane, and
locking screws should not be placed in

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the distal segment until the alignment is

correct22.
Minimally Invasive Plate
Osteosynthesis
The proximal tibial anatomy and fracture
pattern must be clearly understood if
precontoured plates are used with minimally invasive techniques. The articular
surface is visualized with a small arthrotomy, and percutaneous techniques are
used for screw placement into the tibial
shaft (Fig. 5). One must be careful when
this technique is used for plates longer
than eleven holes, as the neurovascular
bundles in the anterior and lateral compartments are at risk12,23.
Locking Screws
Locking screws increase construct rigidity, but they should be placed
bicortically 21,24. They are useful in severely osteoporotic bone, substantial
metaphyseal-diaphyseal comminution,

or short-segment periarticular and/or

intra-articular fractures. Malunion has
been a problem, and it is necessary to
pay meticulous attention to fracture
reduction before placement of locking
screws (Fig. 6)25.
Intramedullary Nailing of Proximal
Tibial Fractures
The use of an intramedullary nail for
fracture stabilization is appealing. The
insertion point of an intramedullary nail
is remote from the fracture site, minimizing vascular disruption of the fracture
fragments, the implants are centrally
located, and tibial diaphyseal fractures
have a high rate of union and low rate of
complications. As a result, the use of
intramedullary nailing for tibial fractures
has expanded from mid-shaft diaphyseal
fractures to proximal fractures26-32. Intramedullary nail fixation is technically
more demanding for proximal tibial
fractures than for diaphyseal fractures.

Fig. 9

Lateral radiographs showing how an inferior starting site and posterior nail trajectory produce a
procurvatum deformity of the proximal segment as the nail enters the diaphysis.

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Fig. 10

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Fig. 11

Fig. 10 Anteroposterior radiograph demonstrating an

appropriate starting site, just medial to the lateral tibial
spine and in line with the mechanical axis. Fig. 11 Lateral
radiograph demonstrating a correctly selected starting
site and wire trajectory. The wire is just anterior to the
articular margin and directed parallel to the anterior tibial
cortex. Fig. 12 Anteroposterior and lateral radiographs
with a protection sleeve for a retropatellar tibial nail
centered at an appropriate starting site.

Fig. 12

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Unlike intramedullary nailing of a diaphyseal fracture, placement of the intramedullary nail does not reduce a
proximal tibial fracture, and malreductions of proximal tibial fractures with
intramedullary nail fixation are reported
to be as high as 84%27,33-36.
The typical deformity caused by
intramedullary nailing of proximal tibial
fractures is valgus and apex anterior
angulation with anterior translation of
the proximal fragment (Fig. 7). The
valgus deformity is due to an imbalance
of muscle forces on the proximal fragment and is accentuated when the
insertion point is too medial or directed
laterally. The tip of the nail can abut the
lateral cortex causing the proximal
fragment to rotate into a valgus position
(Fig. 8)34,35,37. The apex anterior deformity
results from a combination of the pull of
the patellar tendon34, a distal insertion
site, or a posteriorly directed nail that
deflects off the posterior tibial cortex and
rotates the proximal fragment (Fig. 9).
Nails with an accentuated distal Herzog
bend may translate the proximal fragment anteriorly, described by Henley
et al. as the wedge effect38.
To prevent malalignment of
proximal tibial fractures during intramedullary nailing, one should properly
place the starting point; reduce the
fracture prior to guidewire placement,
reaming, and nail insertion; and hold
the reduction until all of the locking
bolts have been inserted.

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Fig. 13

Anteroposterior and lateral radiographs with a proximal Schanz pin for the AO distractor, appropriately
placed parallel to the articular surface (left) and posterior to the nail path (right).

the leg affects fracture reduction. When

the knee is maximally flexed, which
facilitates collinear insertion of the nail

with the anterior tibial cortex, the pull of

the patellar tendon increases the apex
anterior deformity. When this occurs, the

The Proper Starting Point

Fluoroscopic imaging is used to obtain
good anteroposterior and lateral C-arm
images of the knee. The starting point
on the anteroposterior radiograph is in
line with the medial border of the lateral
tibial spine (Fig. 10). The insertion site
on the lateral radiograph is slightly
anterior to the anterior margin of the
articular surface. The guidewire and nail
are inserted as parallel to the anterior
cortex as possible (Fig. 11).
Fracture Reduction Techniques
Extended Leg Position
It is critical to reduce the fracture and
maintain the reduction during fracture
fixation. The intraoperative position of

Fig. 14

Anteroposterior and lateral radiographs demonstrating an appropriately placed distal Schanz pin
inserted parallel to the ankle joint and posterior to the nail path.

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apex deformity can be limited by placing

the instrumentation in the leg with
minimal knee flexion39. Originally, semiextended nailing was performed through
a large medial parapatellar incision;
however, it can now be done with a small
suprapatellar incision. The instruments
and nail are passed through protective
sleeves, posterior to the patella to the
proximal part of the tibia (Fig. 12)16.
Recent studies have suggested this technique can be used without injury to the
patella or femoral articular cartilage, the
menisci, or the anterior cruciate ligament16,18,40. No outcomes data are available for this technique.
Use of a Femoral Distractor or an
External Fixation Frame
A universal distractor or an external
fixator can be used to obtain and
maintain fracture reduction. With use
of fluoroscopic imaging, a proximal
Schanz pin is inserted from the medial
side of the proximal part of the tibia
posterior to the planned intramedullary nail path (Fig. 13), and a distal
Schanz pin is placed medially in the
posterior malleolus (behind the nail) or
at the level of the physeal scar (Fig. 14).
The pins should be inserted parallel
to the proximal and distal joint lines.
Application of traction through the
frame until the pins are parallel typically results in adequate reduction34,41.
Temporary Plate Fixation
A small plate can be used as a temporary
reduction device29,42. The plate may be
placed on the medial or lateral tibial
border, but the medial border is better
since the medial side of the fracture is
often less comminuted. The medial
incision is positioned posterior to the
posterior borders of the tibia so that if
the incision fails to heal, no bone will be
exposed (Fig. 15). Minimal deep dissection is needed, and the plate is placed
over intact periosteum. Unicortical
screws are used so the reamer and nail
can pass. After insertion of the nail and
all interlocking screws, the plate may be
removed or the screws on the proximal
side of the fracture may be taken out.
The plate then acts as a buttress construct, preventing a deformity from

Fig. 15

Anteroposterior and lateral radiographs with a provisional locking plate on the posteromedial tibial
cortex. Unicortical locking screws are used so as to not obstruct insertion of reamers or the intramedullary implant.

recurring while permitting relative motion at the fracture site.

Blocking Screws
So-called blocking or Poller screws can
be used during intramedullary nailing
of proximal tibial fractures. They are
placed preemptively in an effort to
prevent a deformity or as a so-called
bailout after deformity has occurred.
They are used to narrow the canal, to
create a path, or as an artificial cortex
for the nail to pass down28,33,43.
Blocking screws are inserted perpendicular to the plane of the deformity,
on the concave side of the deformity,
within the more mobile fracture segment.
For example, with a valgus deformity, the
screw is placed from anterior to posterior,
on the lateral side of the instrument path,
and in the proximal segment (Fig. 16).

The screw functions as a so-called artificial cortex.

Blocking screws can also be used
for an anterior malalignment. The
blocking screw is placed slightly posterior to the midline, from medial to
lateral, in the proximal fragment (Fig.
16). As a nail is inserted, it contacts the
blocking screw, extending the proximal
fragment and decreasing the apex anterior deformity. The screw should not be
placed in the midline since nail passage
may be blocked by the screw.
Percutaneous Clamps
The orientation of a fracture line may
allow percutaneous placement of a
reduction clamp to obtain and maintain
the reduction (Fig. 17). The use of
clamps has not been shown to increase
infection rates44.

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have been reported, but the union rate

following primary fixation is approximately 77%28,29,36,42. Lindvall et al. reported a 100% union rate for closed
tibial fractures and a 23% rate of nonunion for open fractures stabilized with
an intramedullary nail31.
Patient-specific contraindications to
the use of an intramedullary nail include
open physes, intramedullary canals too
narrow to allow insertion of a nail, preexisting canal deformities, knee contractures, and so-called blocking hardware
such as an ipsilateral knee replacement or
knee fusion. Fracture-specific contraindications to the use of an intramedullary nail
include substantial intra-articular involvement, and short extra-articular segments that preclude placement of at least
two interlocking screws6.

Fig. 16

Anteroposterior and lateral radiographs demonstrating proper positioning of blocking screws to aid in
fracture reduction and strengthen the implant construct. Anterior-posterior screws placed lateral to
the nail (white large arrows) prevent valgus deformation, and medial-lateral screws placed posterior to
the nail (white small arrows) prevent procurvatum.

Implant Selection
It is important to know the implants in
order to ensure that at least two locking
screws can be placed in the proximal
segment. The distance from the end of
the nail to the locking bolts determines
how far proximal or distal fracture lines
can extend and still be stabilized by the
intramedullary nail. The number and
orientation of the proximal and distal
interlocking bolts vary by implant.
Oblique bolts have demonstrated more
stability than transverse bolts in resisting coronal plane deformity, but not
axial or torsional stability38. The combination of oblique and transverse
interlocking screws increases construct
stability45,46. Intramedullary devices
with a distal Herzog bend may accentuate a sagittal plane deformity because,
as the Herzog bend contacts the posterior cortex, it can create a so-called
wedge effect and translate the proximal
segment anteriorly (Fig. 18)38.

Complications and Pitfalls

Knee pain, after intramedullary nailing
of the tibia, affects 60% to 70% of
patients47-50. The anterior knee pain is
exacerbated by kneeling, squatting, stair
climbing, or high-performance athletic
activities. Implant removal after fracture
union has had inconsistent results with
regard to relieving anterior knee pain.
There is no difference in the prevalence
of knee pain when a transpatellar or
parapatellar incision is used.
The prevalence of malunion has
been reported to be as high as 84%36.
With use of the techniques described in
this article, malunion rates have been
reduced to between 8% and 23%28,29,31.
Strict attention to surgical technique
and the use of reduction aids decrease
the prevalence of malreduction.
Infections and nonunions are
most commonly associated with open
and/or comminuted fractures29,31,36,42,51.
Ultimate union rates of 91% to 100%

Nails Compared with Plates

A literature meta-analysis found a trend
toward an increased prevalence of malunion after intramedullary nailing
compared with plate and screw osteosynthesis (p = 0.06), but a lower infection rate after intramedullary nailing
(p < 0.05)52. Lindvall et al. also demonstrated a trend toward a higher malunion rate for intramedullary nailing
(p = 0.103), a threefold increased rate of
hardware removal after plate and screw
fixation, and no difference in implant
failure between these two techniques31.
Both intramedullary nails and plates can
be inserted with use of surgical techniques that respect the local soft-tissue
biology. These techniques optimize
fracture-healing and contribute to a
high rate of fracture union for both
operative procedures27,29,52,53.
Implant failure has been reported
for both intramedullary nails and
plates35,36,53. Early studies of intramedullary
nails had implant failure rates as high as
25%, while only 2.6% of plates failed36,53.
Many early failures of intramedullary nails
involved small-diameter locking bolts24.
More recent literature has demonstrated
similar prevalences of implant failure for
intramedullary nails and plates2,28,31,34,54,55.
Overview
Extra-articular proximal tibial fractures are
technically demanding fractures to treat.

1558
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
V O L U M E 9 3-A N U M B E R 16 A U G U S T 17, 2 011
d

Fig. 17

SURGICAL TECHNIQUES FOR COMPLEX

PROX I M A L TI B I A L FR AC T U R E S

Fig. 18

Fig. 17 Lateral intraoperative radiograph with a Weber clamp placed percutaneously to hold the reduction during nail insertion. Fig. 18 Lateral intraoperative
radiograph with a well-positioned guidewire (parallel to the anterior cortex) during reaming (left). Insertion of a nail with a low Herzog bend (black arrow)
showing displacement of the proximal fragment as it contacts the posterior cortex (right).

Fixation with an intramedullary nail requires a firm understanding of the anatomy of the proximal part of the tibia, the
fracture pattern, the deforming forces, and
the implant system. The prevalence of
malreduction can be reduced with use of
meticulous surgical technique, a correct
nail insertion site, and adjuvant reduction
aids. The rates of postoperative infection
and nonunion are related more to the
nature of the injury (open and comminuted) than to the implant. Patients
should be educated on the occurrence
of postoperative functional knee pain,

which seems to occur more commonly

in younger, more active patients.

Jason A. Lowe, MD
University of Alabama at Birmingham,
510 20th Street South, FOT 960,
Birmingham, AL 35294
Nirmal Tejwani, MD
NYU Orthopedic Surgery Associates,
301 East 17th Street, Suite 1403,
New York, NY 10003

Brad Yoo, MD
Philip Wolinsky, MD
Department of Orthopaedic Surgery,
University of California Davis,
4860 Y Street, Suite 1700,
Sacramento, CA 95817

Printed with permission of the American

Academy of Orthopaedic Surgeons. This article,
as well as other lectures presented at the
Academys Annual Meeting, will be available
in February 2012 in Instructional Course
Lectures, Volume 61. The complete volume
can be ordered online at www.aaos.org, or by
calling 800-626-6726 (8 A.M.-5 P.M., Central time).

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