For antegrade femoral nailing, a stab incision of 15-20mm is made by using a large blade in line with the medullary cavity. The incision moves through the skin and the patellar tendon at the inferior pole of the patella. The knee is bent as much as possible. The centring pin of 4.0mm put on a common chuck with T-handle, forced through the thin cortex towards the centre of the medullary canal. The image enlargement can be helpful to check the position. The protection sleeve for the cannulated cutter is positioned through the stab incision and via patellar ligament straight onto the bone. The cannulated cutter for the medullary canal snips out a cylinder of the cortical cancellous bone which can be used as a bone graft. To prevent an imperfect alignment in proximal fractures, the placement of the starting point precisely in line with the centre of the medullary cavity is important.
Floating knee: antegrade tibial nailing and retrograde femoral nailing
As far as the case of anterograde tibial nailing and retrograde femoral nailing is concerned, both multifix tibia nail system and interlocking nailing system can be used. Both nail insertion can be carried out through the same skin incision. But the surgeon needs to make sure that the incision is sufficiently proximal so that the retrograde nail can be inserted close to the patella.
Tibia Fracture Reduction
As the most tibial fractures are simple A and B type in the midshaft or the distal diaphysis, this type of fractures is suitable manual reduction. During implant insertion, the manual reduction can be used. Manual reduction is a very gentle and effectual instrument for a reduction in fresh tibial fractures. Sometimes the temporary overcorrection of the fracture area can be beneficial and helpful in case of oblique fractures. The distal fragment can easily be felt while manipulation with the tip of the unreamed nail. It can be easily identified by the increased stiffness as the nail goes in the medullary canal of the main distal fragment.
For a critical case like pseudarthrosis with sclerosis of the medullary cavity, distinctively designed hand reamers are safer and effective but for fresh fractures, power reamer is faster and more convenient as compared to hand reamer. Apart from the issues like an increase in pressure and production of heat by reaming, the effect of reamer design such as its sharpness, cutting flutes, and its diameter and geometry was reviewed. It was found that small flutes, blunt reamers, large diameters and high axial forces of the reamer shaft cause a rise in pressure and temperature. The risk of pulmonary embolization depends to a certain extent on different constructs of the reamer. The effectiveness of a distal venting hole largely depends on its diameter. However, the suggested flushing technique of the medullary canal is generally not used but the risk of any complication is less in it. Herein, reaming with an inflated tourniquet is not advisable because normal circulation is an effectual cooling system.