Application of the Alvarado Knee Holder in Infrapatellar Tibial Nail Removal: A Technical Trick

In 1972, Dr. Thomas D. Petersen and his colleagues founded the Alvarado Medical Group in San Diego. The birthplace of total knee arthroplasty (TKA) in the United States and home of the Alvarado Orthopedic Research group, many innovations in arthroplasty trace their invention back to Alvarado Road. One such invention was the Alvarado knee holder, which has become a staple in TKA by allowing for easy adjustment and maintenance of positioning, particularly in degrees of knee flexion. Intramedullary nailing of tibia fractures is now standard practice for most fracture patterns, particularly for tibial shaft fractures that occur in the setting of high-energy trauma. Once the fracture has healed, the implant can either be retained or removed. While implant removal is a relatively common practice, the required technique can be physically challenging without a counterforce to keep the leg in place during the procedure. Removal is performed for many reasons, most commonly anterior knee pain and/or prominence of the implant.1–4 In addition, patients with a history of intramedullary nail placement who present with primary or posttraumatic osteoarthritis significant enough to require TKA or total ankle arthroplasty may require tibial nail removal before further procedures. Other arguments for implant removal in asymptomatic patients include preemptively avoiding implant failure or breakage in the setting of another trauma; avoiding difficult removal secondary to bony overgrowth if the patient were to require implant removal after several decades; and patient request. In addition, implant removal can sometimes be medically necessary, as in the context of infection, exchange nailing, or nonunion repair. The current technique for the removal of infrapatellar tibial nails requires that after general anesthesia, the patient be placed in the supine position with bony prominences padded. After sterile prepping and draping, the patient’s knee is flexed over a radiolucent triangle. Utilizing previous surgical incisions, a midline patellar arthrotomy is made through the patellar tendon. If an endcap is present, it is removed. A guidewire is placed inside the nail and confirmed on anteroposterior and lateral fluoroscopy. After guidewire placement, the extractor either threads or cuts into the implant. Through previous surgical scars, any proximal and distal interlocking screws are removed. The nail is then extracted utilizing a backslap technique, which is often quite forceful. It is during the extraction portion of the procedure that the surgeon and one or multiple assistants are needed to keep the leg stable and maintain the required flexed position. Due to the force necessary to remove tibial nails through an infrapatellar approach, repositioning the patient’s foot and leg to maintain adequate flexion is often required. Moreover, removal can sometimes be difficult resulting in the need for more assistants to hold the leg in a safe and stable position to prevent complications. In the 44 years since Dr. Petersen patented the Alvarado knee holder, we present a technical trick for infrapatellar intramedullary tibial nail removal using the Alvarado knee holder to provide better stability during removal and to reduce operative personnel. TECHNIQUE After general anesthesia, the patient is positioned in the supine position. A bed clamp is attached to the side bed rail. Next, the I-clamp is put into the bed clamp and secures the T-plate (Fig. 1). The lower extremity is prepped and draped in the normal sterile manner. Using prior surgical scars, the distal locking screws are removed. The sliding plate is then secured under the draped T-plate and the patient’s leg is placed in a stockinette and secured in the Alvarado knee holder in the appropriate flexed position of up to 120 to 130 degrees of flexion depending on the patient's body habitus (Fig. 2). A midline patellar incision is made and extended through the patellar tendon. A threaded guidewire is placed and confirmed within the intramedullary nail using intraoperative fluoroscopy on anteroposterior and lateral radiographs. The extractor is threaded into the nail and using prior surgical scars, the proximal interlocking screws are removed (Fig. 3). The nail is then extracted. The patellar tendon arthrotomy is closed in a layered manner with the paratenon and patellar tendon closed in separate layers, followed by all stab incisions closed with a simple nylon suture. Dry sterile dressings are placed.FIGURE 1: Alvarado knee holder, associated equipment, and its attachment to the bed.FIGURE 2: Positioning of the leg after draping.FIGURE 3: Removal of the nail.EXPECTED OUTCOMES The use of the Alvarado knee holder is beneficial with regard to patient safety, positioning, and optimal utilization of operative personnel. In the standard technique, when the nail is backslapped in particularly difficult-to-remove nails, the patient’s leg can shift, requiring an assistant to secure the leg by holding it around the ankle or shin. This is a risk to patient safety as, in difficult-to-remove nails, the patient’s leg could fall off the operative table risking additional injury. Another issue resolved by using the Alvarado knee holder is the maintenance of the positioning. During positioning, the surgeon needs an optimal amount of knee flexion. This can require refinement throughout the procedure as often occurs when the patient’s leg jumps during removal. Instead of requiring the surgeon to readjust the leg, the use of an Alvarado knee holder allows for maintenance of the knee flexion throughout the surgery. In terms of utilization of operative personnel, this technique allows for the procedure to be conducted by the operative surgeon without an assistant. This is advantageous in two settings. One setting is the high-volume, “level-1 trauma” setting where other procedures could benefit from having another assistant. The other is in the community, where there may not be available assistants to help hold the limb in place. COMPLICATIONS Although the use of the Alvarado knee holder is beneficial, there are potential clinical complications associated with its use in tibial nail removal. These complications are pressure ulcers, neuropraxia, and deep vein thrombosis. Each of the complications can be avoided by ensuring that the patient’s leg is adequately padded when placed in the Alvarado and that the patient’s leg is not wrapped too tightly. Rates of complication, whether using the Alvarado or not, are likely to increase with increased operative time. In cases where Alvarado is able to provide a more stable base, making the implant removal process more streamlined and efficient, infection rates seemingly could be decreased as well. CONCLUSION In summary, the benefits of the Alvarado knee holder can be extrapolated from its initial design in arthroplasty to enhancing the ease of tibial intramedullary implant removal. Decreasing the physicality associated with this procedure is important, as the implant removal process can be quite laborious. In addition to making the procedure easier by providing a counterbalance for the backslap technique, it also prevents multiple assistants from having to hold the operative limb in place and can potentially prevent iatrogenic injury to the operative limb.