- Discussion:
            - extended medial parapatellar incision: (from Tornetta and Collins (1996)).
                     - utilize extended medial parapatellar incision, which allow lateral subluxation of patella, and which allows more
                                 proximal and lateral starting hole;
                     - w/ a extended incision, hyperflexion of knee is not required inorder to achieve a proximal starting hole and to keep
                                 reaming parallel to anterior cortex;              
                     - note that hyperflexion of the knee tends to flex the proximal fragment which sends the nail towards the posterior tibial
                                 cortex (which is the biggest pitfall);
                     - patient is position supine with the leg slightly flexed;
                     - mid-line incision is made from superior pole of the patella to the tibial tubercle;
                     - incise through the medial 1/4 of the patellar tendon and continue this incision around the medial pole of the patella (up to its superior border);
                     - retract the patellar tendon and the patella laterally so that the femoral trochlea is exposed;
                     - use flouro to mark out the center of the proximal fragment (AP view);
                     - direct the awl (or starting reamer) just in front of the trochlear surface;
                     - direct hand held reamers parallel to the anterior tibial cortical surface down to the frx site;
                     - take care that the jig apparatus does not injure the trochlear chondral surface as the nail is driven down;
                     - always drain the arthrotomy site; 
                     - references
                            - Intramedullary nailing of tibial fractures: review of surgical techniques and description of a percutaneous lateral suprapatellar approach.
                            - Semiextended position of intramedullary nailing of the proximal tibia.
                            - Tibial Nailing with the Knee Semi-Extended: Review of Techniques and Indications: AAOS Exhibit Selection
                            - One-year Postoperative Knee Pain in Patients With Semi-extended Tibial Nailing Versus Control Group
    outcomes:
           - Tornetta and Collins (1996).
                - 30 patients w/ proximal tibial fractures (16 open, 13 segmental, and 7 comminuted);
                - utilized extended medial parapatellar incision, which allow lateral subluxation of patella, and which allowed more proximal
                                   and lateral starting hole to be achieved.
                       - by using this extended incision, hyperflexion of knee was not required in order to achieve a proximal starting hole and to
                                   keep reaming parallel to anterior cortex;              
                       - note that hyperflexion of the knee tends to flex the proximal fragment which sends the nail towards the posterior tibial
                                   cortex (which is the biggest pitfall);
                - results: 3/25 patients had more than 5 deg angulation and 19 had no anterior angulation;
                - complications and concerns:
                       - one half of patients in this study had open frx, and there is a concern that performing an extended incision (w/ requisite
                                  arthrotomy) might lead to pyearthrosis;
                       - despite this concern, none of these patients developed this complication;
                       - hemarthrosis: developed in one patient (authors recommend routine arthrotomy drainage);
                       - iatrogenic chondral injury: the tibial jig apparatus may scape against the trochlear surface if the knee is not kept slightly flexed;

- References:
        - Semiextended position of intramedullary nailing of the proximal tibia.
        - Semiextended intramedullary nailing of the tibia using a suprapatellar approach: radiographic results and clinical outcomes at a minimum of 12 months follow-up.