Proximal entry for intramedullary nailing of the tibia - The risk of unrecognised articular damage

The risk of articular penetration during tibial nailing is well known, but the incidence of unrecognised damage to joint cartilage has not been descri bed. We have identified this complication in the treatment of tibial fractu res, described the anatomical structures at risk and examined the most appr opriate site of entry for tibial nailing in relation to the shape of the bo ne, the design of the nail and the surgical approach. We studied the relationship between the intra-articular structures of the k nee and the entry point used for nailing in 54 tibiae from cadavers, The re sults showed that the safe zone in some bones is smaller than the size of s tandard reamers and the proximal part of some nails. The structures at risk are the anterior horns of the medial and lateral menisci, the anterior par t of the medial and lateral plateaux and the ligamentum transversum, This w as confirmed by observations made after nailing 12 pairs of cadaver knees. A retrospective radiological analysis of 30 patients who had undergone tibi al nailing identified eight at risk according to the entry point and the si ze of the nail. Unrecognised articular penetration and damage during surger y were confirmed in four. Although intramedullary nailing has been shown to be a successful method fo r treating fractures of the tibia, one of the most common problems after bo ny union is pain in the knee. Unrecognised intra-articular injury of the kn ee may be one cause of this.