Page 4 - SURGICAL TECHNIQUE TIBIA

Step 1: Mark the proximal and distal end of the nail as before.

Step 2: Mark the level of the osteotomy as before.

Step 3: Make a single drill hole anteriorly at the level of the tibial osteotomy. Avoid getting into the anterior compartment. Additional holes can be made medially and posteromedially under the subcutaneous border.

Step 4: Insert temporary arthrodesis screws just proximal to the distal tibiofibular joint. Start with a wire from the fibular side and make sure it passes relatively posteriorly into the tibia. This wire should be oriented distal on the fibula and proximal on the tibia. A second wire of equal length can be used to measure the appropriate length of the screw. Bring the wire out the tibial side and then antegrade drill it with a 3.2-mm cannulated drill bit. Measure and insert a solid (noncannulated) 4.5-mm screw of the correct length antegrade.

Step 5: Make a 3-cm incision posterolateral in the midlevel of the leg. Dissect between the peroneals and gastrosoleus muscles anterior to the intermuscular septum. Dissect down to the fibula. Incise and elevate the periosteum off of the lateral aspect of the fibula and insert a Hohmann elevator anterior and posterior to the fibula. Make multiple drill holes in the fibula with a 1.8-mm wire. Use a narrow osteotome to break the fibula. Confirm that the osteotomy is complete by displacing the osteotomy.

Step 6: Insert a Steinmann pin into the proximal tibia at the level of the joint in line with the medial tibial spine, medial to the patellar tendon. Start as high and posterior as possible. Use an ACL reamer to open the starting point.

Step 7: Ream the tibia in 1-mm increments until there is chatter and then in ½-mm increments until 12.5mm for the 10.7-mm nail and 14.5mm for the 12.5mm nail.

Step 8: Osteotomize the tibia with a sharp osteotome.

Step 9: Insert the Precice tibial nail down the tibia.

Step 10: Orient the upper end of the nail so that the upper medial locking screw is oriented towards the tibiofibular joint. Drill this screw into the head of the fibula. Insert this screw to fix the tibia and fibula. Lock the second proximal locking screw from the lateral side. If the first drill hole and screw misses the fibula, then lock the fibula separately with another 4.5-mm screw in a retrograde manner using a wire and cannulated drill first.

Step 11: Free hand lock 2 of the 3 distal screws leaving either the middle or distal one empty.

Step 12: Perform a distraction test of 1mm using the ERC.