Distal Tibia Medial plating and

screws

 

 

 

1. Case description

   A 65-year-old man fell down a flight of stairs and presented to the emergency department with a chief complaint of left leg pain. Clinically, the patient had significant deformity of his left ankle. The result of neurovascular examination was normal except for swelling. He had a small laceration (< 1 cm) over the fibular fracture where the distal end of the proximal fracture fragment penetrated through the skin. There was no evidence of compartment syndrome. The wound was immediately dressed, and the leg was placed in a splint. Tetanus prophylaxis and intravenous

    

   cefazolin were administered. X-rays of the tibia revealed a fracture of the distal third of the tibia and fibula (Fig-1). Computed tomographic (CT) scan was performed by the emergency department, which demonstrated a distal third tibia fracture with extension into the tibial plafond (AO/OTA 43C2.3) (Fig-2). Irrigation and debridement (I&D) of the open fracture and external fixation of the tibia were done (Fig-3). The patient had a previous ipsilateral total knee arthroplasty.

    

    

   Fig-1a–d Postinjury images taken in the emergency department. a–b AP and lateral x-rays obtained at presentation. c–d AP and lateral x-rays obtained after reduction.

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

    

   minimal articular step-off or displacement.

    

   Fig-3a–b Intraoperative C-arm images taken after I&D and external fixation of the open tibiafibula fracture.

    

2. Preoperativeplanning Indicationsforsurgery

 

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Surgical treatment of this injury is necessary based on the open nature of the injury. Restoration of length, rotation, and alignment of the tibia and fibula, and reconstruction of the plafond injury cannot be achieved with nonoperative treatment.

 

Treatmentoptions

A staged approach, with initial irrigation, debridement of the open fracture, and external fixation of the tibia is essential to minimize complications.

 

Open reduction and internal fixation of the fibula, limited fixation plafond, intramedullary nailing fixation of tibia

This injury ideally could be treated with open reduction and internal fixation (ORIF) of the fibula, limited open reduction of the

Open reduction and internal fixation with direct reduction and plate fixation

The goal of surgical treatment is restoration of the diaphyseal-metaphyseal junction of the tibia with anatomical reduction of the articular surface of the ankle to provide bony union and minimize posttraumatic arthropathy.

 

Based on the x-rays and CT imaging obtained, a posterolateral approach to the fibula and anteromedial approach to the tibia was chosen. Evaluation of the soft-tissue envelope 1 week after external fixation showed that the tissues had recovered sufficiently to allow surgical ORIF. This time allowed the surgeon to formulate an appropriate preoperative plan before proceeding with surgical treatment (Fig-4).

3 Operating	roomsetup
Patient positioning	Supine
Anesthesia options	General, spinal, or regional Avoid regional anesthesia in higherenergy injuries, as it may mask developing compartment syndrome.
C-arm location	Placed on contralateral side of the table with the monitor at the head of the table.
Tourniquet	Used at surgeon's discretion Generally improves visualization
Tips	Placing the injured leg on an elevating ramp improves imaging and allows unobstructed access to the injured extremity.

 

tibial plafond and intramedullary nailing of the tibia. However, the   patient’s total knee arthroplasty precludes intramedullary nail

fixation.

 

 

 

Fig-4 Preoperative plan.

For illustrations and overview of anesthetic considerations, see chapter 1.

 

Equipment

• Headlamp for visualization

• Elevators and dental picks

• External fixator and distractor device

• K-wire set

• Distal tibial plates with small fragment screws

• Locking plates as an alternative

 

 

Ankle Distal tibia

Section 2 Complex articular fractures

Medial plating and screws

 

Size of system, instruments, and implants may vary according to anatomy.

 

 

 

1. Surgicalprocedure

   The fibula is approached using a posterolateral approach. Recreating appropriate length, alignment, and rotation is essential and assists in reconstruction of the tibia (Fig-5). This may be done as an isolated surgical procedure or at the time of fixation of the tibia.

    

   Carefully plan the anteromedial tibial approach to minimize wound complications. The incision is performed 1 cm lateral to the tibial crest, extended to the articular surface of the ankle then extended medially, forming an apex prior to the incision curving medially

    

   (Fig-6). This approach can be extensile proximally. The fascia over the anterior compartment is released and the anterior compartment muscles are retracted laterally after incising the extensor retinaculum. The saphenous nerve and vessels are carefully protected throughout the approach. Subperiosteal dissection of the tibia is performed, creating a full-thickness flap. The entire anterior articular surface of the ankle from medial to lateral can be exposed through this approach (Fig-7). Application of a distractor allows better restoration of length and aids fracture reduction.

    

    

   Fig-5 Intraoperative imaging following fibular reduction and fixation.

    

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   Fig-6a–b

   Surgical approaches to the fibula. (Image of a different patient.) a

   Postero lateral approach. b

    

   Anteromedial approach.

    

    

   Ankle Distal tibia

   Section 2 Complex articular fractures

   Medial plating and screws

    

   Distraction for diaphyseal-metaphyseal reduction and reduction of the articular surface with K-wires is performed. For the case presented here, a medial buttress plate was used, with a smaller anterior plate used to bridge the anterior comminution. Bone grafting of metaphyseal or subchondral defects can be performed

   Be careful to ensure that implants are not impinging within the ankle joint. The external fixator can be left in place for several weeks to maintain articular reduction, especially with comminution or in patients with poor bone density. X-rays are performed at regular intervals postoperatively to assess healing (Fig-9).

    

    

    

    

    

    

   Intraoperative imaging demonstrates reduction of the

   diaphyseal-metaphyseal junction with anatomical restoration of the

    

    

    

    

    

   AP view.

    

    

    

    

    

    

    

   AP view.

    

    

    

   Lateral view showing proximal hardware.

    

    

   (Fig-8).

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2. Pitfallsandcomplications

    

   Pitfalls

   Inadequate reduction and fixation The choice of approach is critical in successful reduction and fixation strategies for these injuries. A poorly planned surgical approach may not allow adequate visualization of the articular injury and appropriate fixation. The CT scan is the investigation of choice to formulate a preoperative plan that is appropriate for each unique fracture.

    

   Distractor use

   The surgeon should become familiar with a distractor device, whether the older large femoral distractor or the newer rack and pinion device. This instrument becomes a critical tool for visualization and for achieving fracture reduction. Placement of Schanz pins should be well planned according to the fracture pattern.

    

   Irreducible intercalary fragments Remove small intercalary fragments (ie, < 5 mm in diameter) and fragments without adequate overlying cartilage rather than attempting fixation. These fragments do not contribute to joint congruity and may impede anatomical reduction or may displace into the joint as loose bodies.

    

   Complications

   • Injury to the anterior neurovascular bundle

   • Injury to the saphenous nerve or vessels

   • Intraarticular placement of implants

   • Loss of fixation

   • Nonunion

   • Malunion

   • Avascular necrosis

   • Posttraumatic arthritis

   • Compartment syndrome

   • Infection

   • Wound complications

    

    

3. Alternative techniques

    

   Ideally, intramedullary nail fixation with limited ORIF of the articular surface is used for this fracture. However, the patient’s previous ipsilateral total knee arthroplasty precludes this approach. A minimally invasive medial tibial plate could have been used for this distal tibial injury. A thin wire fixator is another treatment option.

4. Postoperativemanagementandrehabilitation

    

   Postoperatively, immobilize the ankle in a splint or fracture brace, with the ankle held at 90°. Always keep the leg elevated. On postoperative day 1 or day 2 remove any applied suction drain. Keep sutures in place for 2–3 weeks, then remove. If the external fixator is retained, remove it several weeks postoperatively with the timing based on fracture severity. Toe range of motion (ROM) is encouraged immediately after surgery, which helps prevent deep vein thrombosis and maintains metatarsophalangeal motion. Start active and passive ROM exercises of the ankle as soon as the external fixator is removed.

    

   Nonweight bearing is recommended for 8–12 weeks postoperatively depending on fracture severity. Standard postoperative x-rays are obtained to ensure fracture union. If uncertain of fracture healing, obtain a postoperative CT scan. An active rehabilitation program is initiated at weight bearing to emphasize ROM, muscular balance, and gait training.

    

   Implantremoval

   Removal of plates and screws for tibial and pilon fractures can be performed at 1 year if the patient experiences hardware-related pain. Implants can be retained long-term if there is no pain or hardware prominence.

    

    

5. Recommended reading Acknowledgement

 

BlauthM,BastianL,KrettekC,etal. Surgical options for the Special thanks to Miyoko Green in her assistance with treatment of severe tibial pilon fractures: a study of three techniques. J Orthop Trauma. 2001 Mar–Apr;15(3):153–160. preparation of this chapter.

ChenL,O’SheaK,EarlyJS. The use of medial and lateral surgical approaches for the treatment of tibial plafond fractures. J Orthop Trauma. 2007 Mar;21(3):207–211.

DiGiorgioL,TouloupakisG,TheodorakisE,etal. A two-choice strategy through a medial tibial approach for the treatment of pilon

fractures with posterior or anterior fragmentation. Chin J Traumatol. 2013;16(5):272–276.

LeeT,BlitzNM,RushSM. Percutaneous contoured locking plate fixation of the pilon fracture: surgical technique. J Foot Ankle Surg. 2008 Nov–Dec;47(6):598–602.

 

 

Ankle Distal tibia

Section 2 Complex articular fractures

Medial plating and screws LiporaceFA,YoonRS. An adjunct to percutaneous plate insertion to obtain optimal sagittal plane alignment in the treatment of pilon fractures. J Foot Ankle Surg. 2012 Mar–Apr;51(2):275–277. PaluvadiSV,LalH,MittalD,etal.

Management of fractures of the distal third tibia by minimally invasive

plate osteosynthesis—a prospective series of 50 patients. J Clin Orthop Trauma. 2014 Sep;5(3):129–136.

PattersonMJ,ColeJD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma. 1999 Feb;13(2):85–91.

SirkinM,SandersR. The treatment of pilon fractures. Orthop Clin North Am. 2001 Jan;32(1):91–102.

 

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