Right Distal Tibial Oblique Fracture Open Reduction and Internal Fixation (ORIF) with Medial Neutralization Non-locking Plate
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Table of Contents
Diaphyseal tibial fractures are common injuries that are most often treated with intramedullary nailing. However, certain patient factors may necessitate alternative treatment strategies such as open reduction internal fixation (ORIF) with plates and screws. Presence of a total knee arthroplasty (TKA) in the injured extremity is one such factor. TKA is a common operation that is only increasing in popularity, and management of tibia fractures distal to TKA may be a frequently encountered clinical scenario. In this video, we present a technique for ORIF of a distal diaphyseal tibia fracture distal to a TKA that precludes intramedullary nail fixation. The fracture is fixed with lag screws and secured with an anatomically-contoured distal tibia locking-compression plate (LCP) in neutralization mode.
Diaphyseal tibia fractures are relatively common injuries, occurring in 21.5 per 100,000 people and accounting for 1.9% of all fractures in adults.1 17% of these fractures occur in patients >65 years old.1 Intramedullary nailing, open reduction internal fixation (ORIF) with plate-and-screw constructs, and casting are all viable treatment options.2 Reamed intramedullary nailing is the standard intervention for diaphyseal tibia fractures as this procedure involves minimal soft tissue violation while resulting in reliable union rates.3 However, choice of treatment may be influenced by specific patient factors. One such factor is presence of a total knee arthroplasty (TKA) in the injured leg. In the United States, 7.3% of adults over age 70 have undergone TKA, and the frequency with which this operation is performed is projected to accelerate in the coming years.4,5 The presence of a TKA tibial component in a fractured tibia may block access to the ideal entry point for an intramedullary nail and increase the risk of associated iatrogenic tibial tubercle fracture. While intramedullary nailing below a TKA is a well described option in the hands of experienced surgeons when there is adequate space anteriorly, ORIF may be a preferable option if the tibia fracture is to be treated operatively and there is too little space to safely accommodate a nail.
Focused history should include the patient’s age and medical history and provide an understanding of the mechanism of injury. It is important to elicit any history of prior operations on the injured extremity such as existing surgical implants that may limit surgical options for addressing the acute injury, and prior surgical scars that may dictate the location of planned incisions. Special attention should be paid to the patient’s baseline functional status including home living situation and dependence on assistive devices for mobilization.
The patient in this case is a 59-year-old female who sustained a twisting injury to the right lower extremity during a presyncopal episode, after which she was unable to bear weight. Her past medical history is significant for prior traumatic brain injury, diabetes mellitus type 2, hypertension, depression, and anxiety. She had previously undergone a right TKA several years prior to sustaining this injury. She lives alone and is independently mobile without use of a walker or cane.
Upon initial evaluation in the emergency department, the injured right lower extremity was placed into a plaster long-leg splint for provisional stabilization. This splint uses posterior, medial, and lateral slabs to immobilize the knee and ankle while controlling rotation of the fractured tibia.
Important elements of physical exam include assessment for open wounds and a detailed neurovascular assessment. Existing surgical scars should be noted. Diaphyseal tibia fractures are at high risk of developing compartment syndrome, and serial examinations must be performed. Firmness of the anterior, lateral, and/or posterior muscular compartments of the leg, paresthesias in the foot, and pain with passive range of motion of the toes are signs concerning for developing compartment syndrome. Compartment syndrome has been reported in 11.5% of tibial fractures and is most likely to occur in younger patients under 30 years of age.6
In this case, the patient’s vital signs were stable. There was gross deformity of the right lower extremity with the ankle externally rotated relative to the knee. There were no injuries to the skin of the extremity. Muscular compartments of the leg were soft and compressible to palpation. She was able to move all toes without significant pain. Sensation was intact in the distributions of the superficial peroneal, deep peroneal, tibial, sural, and saphenous nerves in the foot. She had palpable deep peroneal and dorsalis pedis pulses.
Plain radiographs of the whole tibia and fibula should be obtained preoperatively. Extension of spiral or oblique fractures of the distal 1/3 of the tibial diaphysis into the distal articular surface (also referred to as the tibial plafond) may necessitate additional fixation and should be evaluated with dedicated anteroposterior (AP), lateral, and mortise (15–20° internal rotation oblique) radiographs of the ankle. In most cases a computed tomography (CT) scan of the distal fracture fragment including the articular surface is performed to evaluate for intra-articular extension. A series of CT findings in spiral distal 1/3 tibial diaphyseal fractures reported posterior malleolus fractures in 92.3% of cases, 50% of which were not apparent on plain radiographs. Posterior malleolus fracture is commonly associated specifically with a spiral distal 1/3 fracture pattern.7 A previous series based on plain radiographs identified posterior malleolus fractures in only 3.8% of all tibia fractures of all patterns.8
Radiographs in this case demonstrated a spiral fracture in the distal 1/3 of the tibial diaphysis, in the region of the meta-diaphyseal junction. Extension of the spiral fracture line towards the distal tibial articular surface was apparent on plain radiographs, and thus a CT was obtained. The CT showed extension of the fracture line to the posterior malleolus without displacement.
Left untreated, diaphyseal tibia fractures are at high risk for nonunion or malunion that would cause significant continued pain and loss of mobility. Due to the subcutaneous position of the tibia, an untreated fracture would also be at high risk of conversion to an open, or importunate, fracture. For these reasons, diaphyseal tibial fractures require active closed or open treatment in nearly all cases.
Historically, diaphyseal tibia fractures have been retreated with both closed management including casting and functional bracing and by open methods such as ORIF with plate-and-screw constructs and intramedullary nailing.
Non-operative, closed management entails initial closed reduction with placement of a long-leg plaster splint or fiberglass cast for 2–4 weeks, followed by conversion to a short-leg patellar-tendon-bearing cast or functional brace which is worn for up to 10–12 weeks postinjury.9 Patients return to clinic every 2–4 weeks for serial radiographs to confirm maintenance of reduction. If alignment shifts to an unacceptable degree, operative intervention may be indicated. No weightbearing is allowed for several weeks until there is evidence of robust callus formation.
In ORIF, an incision is made and dissection is carried out through the soft tissues to expose the fractured bone. The incision is centered on the fracture site and extended several centimeters proximally and distally to allow adequate exposure. The medial tibial surface is subcutaneous and can be easily exposed through an incision just medial to the tibial crest; an incision is made through the dermis and blunt dissection is used to expose the periosteum at the fracture site. Attempts should be made to preserve periosteal integrity as much as possible. The lateral surface of the tibia is exposed by incising the crural fascia just lateral to the tibial crest and elevating the anterior compartment musculature. Fractures amenable to anatomic reduction are reduced typically with multiple Weber pointed reduction clamps and fixed with a plate-and-screw construct. 3.5-millimeter (mm) and/or 2.7-mm screws may be placed using lag technique to hold the reduction and provide compression. An anatomically contoured, 3.5-mm locking-compression plate (LCP) is then placed in neutralization mode. The plate should be long enough to span the fracture and allow for at least 3 screws (6 cortices of fixation) proximal and distal to the fracture site. In very thin patients, the soft tissue envelope over the medial tibia may be so thin that the plate is very prominent or there may be too much tension for safe closure of the incision; in these cases, a plate can alternatively be placed on the lateral surface below the anterior compartment musculature. Similarly, in high-energy injuries the medial soft tissues may be too compromised to safely accommodate a closure under tension, lateral plating may be preferred. In comminuted fractures that demand a functional reduction, reduction is obtained via a combination of closed manipulation and percutaneous clamping, and a 3.5-mm LCP is applied in bridging mode. In this case, the plate may be inserted in a minimally-invasive fashion using a small incision at the proximal or distal end, slid extraperiosteally, and held with percutaneously placed screws. In either case, the leg is splinted postoperatively and weightbearing is limited for several weeks.
Intramedullary nails are inserted through small incisions around the knee. A functional reduction is obtained using a combination of closed manipulation and percutaneous clamping. A guide pin is used to identify the ideal entry point just medial to the lateral tibial spine and just anterior to the articular surface.9 The canal is then sequentially reamed to allow insertion of a sufficiently sized nail, typically 9–11mm in diameter. The nail is fixed proximally and distally with screws inserted through percutaneous stab incisions. Immediate weightbearing is typically allowed after intramedullary nailing.
The goals of treatment for diaphyseal tibia fractures are to restore functional length, alignment, and rotation of the fractured bone in order to return the patient to early mobility and function.
In this middle-aged, active, community ambulator, operative intervention was indicated to minimize time to full weightbearing and optimize alignment of the injured limb. The presence of a TKA in the injured tibia led to the decision for ORIF with a plate and screws over an intramedullary nail. The relatively simple spiral-oblique fracture pattern allowed for anatomic reduction of the fracture that could be fixed with lag screws and a plate in neutralization mode.
Presence of a TKA in the injured extremity may complicate placement of an intramedullary nail. Nailing around the tibial baseplate is an advanced technique and can only be safely performed when there is sufficient space between the existing prosthesis and the anterior cortex.10 The risks of nail insertion are displacing the prosthesis or causing an iatrogenic tibial tubercle fracture. If there is too little space for safe nail insertion, ORIF should be performed.
Diaphyseal tibial fractures are common injuries that may result in severe functional limitations if not appropriately treated. These fractures can be managed non-operatively with serial casting and/or functional bracing, or operatively with ORIF or intramedullary nailing. In most cases, these fractures are treated operatively with reamed intramedullary nailing, which is the standard of care.3,11 However, certain patient factors, such as presence of a TKA with limited anterior bone stock, may make ORIF a preferred option. In this case we performed ORIF of a distal diaphyseal tibial fracture distal to a TKA using lag screw fixation with a medial non-locking neutralization plate.
Non-operative, closed management of diaphyseal tibia fractures may be indicated if casting and bracing are able to maintain strict alignment parameters of length, coronal and sagittal plane alignment, and rotation. Previously cited acceptable parameters are varus/valgus angulation <5°, procurvatum/recurvatum <5–10°, rotation 0–10°, and shortening <10–12mm.9 Alignment is initially maintained via a long-leg plaster splint or fiberglass cast followed by a longer period in a short-leg patellar-tendon-bearing cast or functional brace.9 If alignment shifts outside the acceptable parameters at any time, conversion to operative treatment is indicated. Non-operative management via these methods can be onerous for both surgeons and patients and has been associated with increased rates of nonunion (17%) and malunion (32%) compared to surgical techniques.2 For these reasons, most surgeons elect for operative management.11
Both ORIF and intramedullary nailing can lead to successful results. Modern plating techniques using minimally-sized incisions, careful soft tissue handing, and low-profile, anatomically-contoured locking plates can reduce the risk of infection, wound complications, and periosteal stripping that may contribute to risk of nounion.12 ORIF does require a period of splinting and non- or partial-weightbearing immediately postoperatively. Intramedullary nails are inserted through relatively small incisions and result in less soft tissue disruption. Immediate weightbearing-as-tolerated is typically allowed after intramedullary fixation unless there is fracture extension into the tibial plafond. Many studies have compared ORIF and intramedullary nailing for diaphyseal tibia fractures, including several randomized controlled trials (RCTs). Regarding fractures in the distal tibial diaphysis specifically, studies have generally shown higher rates of malalignment with intramedullary nails with similar rates of deep infection and nonunion.12 Rates of malalignment of distal tibia fractures have been reported to be between 8–50% for intramedullary nailing versus 0–17% for ORIF.12 Deep infection is relatively rare with either operation (0–8%).12 Reported rates of nonunion are similar after intramedullary nailing and ORIF, between 3–25%, though some literature suggests slower healing with use of locking plates specifically.12 A recent large RCT of 258 operatively treated distal tibia fractures found no difference in patient self-reported disability or quality of life between ORIF and intramedullary nailing at 12 months postoperatively, though patients who underwent intramedullary nailing reported lower disability at 3 months.13 A follow-up study at 5 years postoperatively similarly found no difference in patient reported outcomes and no difference in rates of reoperation.14 This long-term follow-up study also found that patients’ reported level of disability did not change after the first 12 months after either operation.14
Plates for ORIF can be placed on either the medial or lateral surfaces of the tibia. Medial plating is convenient as the subcutaneous tibia is easily accessed, while exposing the lateral tibia for plating requires lifting off the anterior compartment musculature. Though open lateral plating requires greater dissection and exposure, the more robust soft tissue envelope is also protective against wound complications and plate prominence that are more common with medial plating.15 If considering medial plating, the surgeon should carefully access the thickness of the medial skin and subcutaneous fat and should take into consideration host factors that may influence wound healing, including age, diabetes, obesity, and tobacco use.12 Minimally-invasive, percutaneous plating techniques that minimize the size of incisions and soft tissue stripping have been described for both the medial and lateral tibia.
Intramedullary nail insertion is more complicated when there is a previously implanted TKA in the injured extremity. Historically, surgeons have opted for ORIF for treatment of diaphyseal tibial fractures distal to a TKA out of concern for displacing the tibial base plate or causing an iatrogenic tibial tubercle fracture. More recently techniques for inserting a nail in the presence of a TKA have been reported. In 2022, Shaath et al. reported successful nailing of 9 fractures with no incidence of nonunion, infection, or arthroplasty complications.10 In their series, the mean distance from the tibial tubercle cortical density to the keel of the TKA tibial component was 24.1 mm, with a minimum distance of 19.5 mm. They were able to insert nails up to 11 mm.10 Also in 2022, Stevens et al. reported successful nailing with a minimum of 14.8 mm between the implant and anterior cortex.16 While these series show that intramedullary nailing can be successful in the presence of a TKA, this is an advanced technique that requires a high level of skill with intramedullary nailing and comfort managing the potential intraoperative complications should they arise. Tips for performing intramedullary nailing below a TKA include using a 2.0-mm Kirschner wire to find the start point and sound the path of the nail, utilizing a posterior blocking screw distal to the TKA tibial component, maintaining anterior trajectory of the ball-tipped guidewire with a cannulated awl or Yankauer suction tip, and passing reamers and the nail slowly around the TKA baseplate.10,16
In the case described in this video, there was felt to be insufficient space for safe passage of an intramedullary nail as the distance from the tibial tubercle cortical density to the TKA tibial component keel measured 16 mm. ORIF was thus performed. The fracture was reduced through an anteromedial incision and fixed with two 3.5-mm lag screws. A 3.5-mm LCP was then applied to the medial surface of the tibia. There was no displacement of the posterior malleolus fracture fragment, and no fixation was performed due to the small size of the fragment and the expectation that the patient would be non-weightbearing initially postoperatively. The operative time was 64 minutes and blood loss was 100 milliliters.
The patient’s postoperative course was uncomplicated. She was initially placed into a plaster splint, which was transitioned to a controlled ankle motion (CAM) boot at 2 weeks postoperatively. Her weightbearing was advanced to 50% at 6 weeks postoperatively and then to full weightbearing as tolerated at 12 weeks. At her most recent follow-up a 5 months, she had minimal pain with full weightbearing and no limitation in ankle range of motion compared to the uninjured contralateral side, and her fracture was found to be fully healed radiographically.
- Anatomically-contoured distal tibial locking-compression plates
- Weber reduction clamps of various sizes
- Small fragment locking and non-locking screws
Citations
- Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691-697. doi:10.1016/j.injury.2006.04.130.
- Coles CP, Gross M. Closed tibial shaft fractures: management and treatment complications. A review of the prospective literature. Can J Surg. 2000;43(4).
-
Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators; Bhandari M, Guyatt G, Tornetta P 3rd, Schemitsch EH, Swiontkowski M, Sanders D, Walter SD. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 2008 Dec;90(12):2567-78. doi:10.2106/JBJS.G.01694.
- Kremers HM, Larson DR, Crowson CS, et al. Prevalence of total hip and knee replacement in the United States. J Bone Jt Surg - Am Vol. 2014;97(17):1386-1397. doi:10.2106/JBJS.N.01141.
- Shichman I, Askew N, Habibi A, et al. Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2040-2060. JBJS Open Access. 2023;8(1):e22.00112. doi:10.1016/j.artd.2023.101152.
- McQueen MM, Duckworth AD, Aitken SA, Sharma RA, Court-Brown CM. Predictors of compartment syndrome after tibial fracture. J Orthop Trauma. 2015;29(10):451-455. doi:10.1097/BOT.0000000000000347.
- Sobol GL, Shaath MK, Reilly MC, Adams MR, Sirkin MS. The incidence of posterior malleolar involvement in distal spiral tibia fractures: is it higher than we think? J Orthop Trauma. 2018;32(11):543-547. doi:10.1097/BOT.0000000000001307.
- Stuermer EK, Stuermer KM. Tibial shaft fracture and ankle joint injury. J Orthop Trauma. 2008;22(2):107-112. doi:10.1097/BOT.0b013e31816080bd.
- Boulton C, O’Toole RV. Tibia and Fibula Shaft Fractures. In: Tornetta P, Ricci WM, Ostrum RF, McQueen MM, McKee MD, Court-Brown CM, eds. Rockwood and Green’s Fractures in Adults, Ninth Edition. Philadelphia, PA: Wolters Kluwer; 2020:2687-2751.
- Shaath MK, Avilucea FR, Kerr M, et al. Treatment of diaphyseal tibial fractures distal to a total knee arthroplasty by intramedullary nailing is safe and effective. J Orthop Trauma. 2022;36(12):639-642. doi:10.1097/BOT.0000000000002438.
- Busse JW, Morton E, Lacchetti C, Guyatt GH, Bhandari M. Current management of tibial shaft fractures: a survey of 450 Canadian orthopedic trauma surgeons. Acta Orthop. 2008;79(5):689-694. doi:10.1080/17453670810016722.
- Vallier HA. Current evidence: plate versus intramedullary nail for fixation of distal tibia fractures in 2016. J Orthop Trauma. 2016;30(11):S2-S6. doi:10.1097/BOT.0000000000000692.
- Costa ML, Achten J, Griffin J, et al. Effect of locking plate fixation vs intramedullary nail fixation on 6-month disability among adults with displaced fracture of the distal tibia: the UK FixDT randomized clinical trial. JAMA. 2017;318(18):1767-1776. doi:10.1001/JAMA.2017.16429.
- Parsons N, Achten J, Costa ML. Five-year outcomes for patients with a displaced fracture of the distal tibia. Bone Joint J. 2023;105-B(7):795-800. doi:10.1302/0301-620X.105B7.BJJ-2022-1419.R1.
- Kumar D, Mittal A, Singh J, et al. Anterolateral and medial locking compression plates for the management of distal tibial fractures: a comparative prospective study. Cureus. 2023;15(8):e44235. doi:10.7759/cureus.44235.
- Stevens NM, Tyler AF, Mitchell PM, Stinner DJ. Preoperative and intraoperative considerations using intramedullary nails for the treatment of tibial shaft fractures below total knee arthroplasty. J Orthop Trauma. 2022;36(11):e437-e441. doi:10.1097/BOT.0000000000002367.
Cite this article
Hresko AM, Rodriguez EK. Right distal tibial oblique fracture open reduction and internal fixation (ORIF) with medial neutralization non-locking plate. J Med Insight. 2024;2024(444). doi:10.24296/jomi/444.
Procedure Outline
Table of Contents
Transcription
CHAPTER 1
My name is Ken Rodriguez. I'm the Chief of Orthopaedics at Beth Israel Deaconess Medical Center. I'm a trauma surgeon and I take care of a gamut of cases ranging from high-energy trauma to geriatrics mostly. We have a couple of cases scheduled for today that came in last night. My first case is a 59-year-old female patient who fell down and had a torsion injury to her limb sustaining a distal tibia closed fracture, and a very spiral, fairly simple extra particular pattern. The issue with her is that she has a total knee replacement immediately above the tibia shaft fracture. So she would not be a candidate for our typical management, which is an intramedullary nail. So we will have to actually plate a tibia, which is something very classic and an operation that we don't often do anymore. But it's a good basic principles type of operation.
CHAPTER 2
So the interesting part about this is that it's a tibial shaft, but it's a very, very distal tibial shaft, right? So you measured it in the CT scan to have like six millimeters from the actual joint. So as a tibial shaft fracture, it would be amenable to intramedullary nailing, which is the standard of care. But this is - we're not doing that for two reasons. First of all, the fracture is very distal, so you may not grab enough of the distal piece of the tibia to actually be able to secure the stability, but most importantly, this scar represents a total knee replacement. So, the angle, the entry position for the IM nail is gonna be very hard. Her tibia actually has a very little space. Occasionally, we have done intramedullary nails around tibial prosthetics, but it's usually when the prosthetic lies a little bit posterior and you have a safe spot to put the nail somewhat more anteriorly. The risk with that is that if you're putting your nail too anteriorly to avoid the knee, you can damage the tubercle. And if you get a tubercle fracture, that's like a big problem. Yes. Right? That's almost as worse problem than what we're trying to solve. So for her, we're gonna do a more traditional medial plating, you know, and there's two approaches to it. You can actually just open it up and take a look, clamp it, and put a screw across it, and then put a plate that's called a neutralization plate. Neutralization because it neutralizes the forces acting on the screw that you put initially across the fracture plane, which is what define what does your fracture. Sometimes, if you can reduce it beautifully, you could potentially do a percutaneous technique, which is a little bit safer on the skin. But the important thing here is to make sure you get the reduction done adequately. So once you start by bringing the C-arm on and mark the margins of the fracture, I will stabilize the... Internally rotate a little bit here, Andrew? Yep. Coming in, coming in, distal, please. Almost like an angle shot, a little bit more. A little bit more into the fracture, awesome. Okay, everyone protected with the lead? Okay, fire. Make a mark there across, that's your proximal aspect. Could you go all the way to the knee first and mark where the end of the prosthetic is? Picture there, please. We got way - a lot of safety area, right, okay. Make a mark there. The point is, if we're gonna put a plate, you have to span the fracture but not get so close to the prosthetic that it's gonna be a problem, both in terms of running into the prosthetic or creating a stress fracture. Picture there, please. Okay, go a bit more generously distal 'cause I think we measured it. Picture. Picture. Put your picture device again. Yeah. Picture. Yeah, make a mark there. And then the final thing is you mark the actual joint. So make a corner, the anterolateral corner. Picture. Okay, make a little mark right there. Okay, make a little line here. Awesome, okay, all right. You can step out with the C-arm for a second. So we know that's the proximal aspect of the fracture is there, so most of our reduction work is gonna be done here. Hold it there, okay. I'll take the marking pen. Just keep it neutral. Oh, okay. Yeah, okay. So what we usually do, I usually kind of find the joint, which we marked this time, right? You can feel right there, the little angle, right? So it's something like this. So if you're gonna slide a plate, the plate's gonna be somewhere over here. So I try to make my incision a little bit more anterior so that you're not putting a suture line on the plate. So if we're gonna open distally, I think we can probably start doing something like this as the distal incision - go a little bit more... A little bit more distal, so we can slide the plate up if we have to. Then we know this is the crest. The crest is here. So we know our reduction is gonna be here. So we're gonna probably open up here, right? To kind of get a reduction. And then slide the plate and potentially go in this direction here. So why don't, let's start by opening here, here to here. Go ahead, Andrew.
CHAPTER 3
All right, we're making our incision. Yeah, and I'll take a forceps and a self-retractor of some sort, like a Weitlaner or something. I'll borrow the Bovie from you, I'll take the other one. That's great, you can put that there. Just gimme a little bit of traction. What's the Bovie at, guys? 40/40. Great, thank you, so you can feel already that you're giving the fracture right there. Usually, you'll find that the tissue's a bit stripped, right, just because of the trauma, right? So I'm looking at this, right? Our fracture is oblique and extending distally. So, let's see if we can see it. There you go, right, you can sense it there. Let's just see if we can actually see anything. I think it's up here, right? And it's nicely covered by periosteum, which is great, right? If there's a chance that we can fix this without taking down the periosteum, that's actually a desirable thing. Because this was the upper end of the... Yeah, that's what's weird. But we may have just - feel this... When you move this, right? Yes. It's kind of hard to appreciate it. Can I have a freer, please? All right, let's take a look at the... It's not very obvious, is it? There it is, it's right here. Okay, so, this is the distal apex, right? So it's a bit more lateral than what you would think. That's fine, so we, that's great 'cause then we can open here, right? And move and elevate the lateral muscles a bit better. There you go, put your finger there and feel it over there, right? Yep. So let's move this here. We can start reducing it and it's gonna be a great area to put this in. Okay, so can we take a reduction clamp, please? Let me see what options we have. Do you have the medium reduction clamps? Thank you. And let's try this. I'll try another.
CHAPTER 4
So feel that, guys, right, feel that there. Oh, yeah. You can see. So we have mapped it to be somewhat like this, so we're gonna... You wanna give it a try and see if you can reduce it? Sure. Yeah. So put one clamp on the behind and see. So what I would do is I would actually use your left hand for this. Okay. And use your right hand to control your traction a little bit, right? And what we'll do is... So hook your... There's the fracture plane. It's really visible, see? See it there? Mm-hmm. So go a little bit behind it. Because it's over the spiral. Yeah, there you go, right? And now get in there on this side here, right? Yeah. Right, gonna get this out. Okay, and now pull on it, right? And kind of like you're a little bit... You're a little bit oblique. Try clamping there, see what happens. Posterior on the heel. Yeah, it's okay. Take your time. Not the place you wanna... Right, so we're trying to do this without really damaging the periosteum, right? I'm gonna traction on you, right, that looks pretty good. A little bit off still. So let me just adjust for you a little bit. Let's just... Let's just bring you up a touch like this, right? Yep, oh, now I see it. Oh, do you see it there, right, it's a bit more obvious, so give that a try now. There you go, right, wiggle it, wiggle it, wiggle it. Okay, start clamping. There you go, right, see how nice it looks, okay? And now while you hold it there, I'm gonna reinforce you. Nah, this one doesn't lock... Can I have a different one, guys? This one doesn't click shut. The reason why you can't leave the clamp is because it's in the way of the plate. So, otherwise, you know, well what we can do is we have a very nice alignment. I'm gonna reinforce it with this. And you guys see the nature of the fracture, right? Yeah. So we're gonna be able to put a couple of good, it's oblique like this, so why don't we aim for a couple of lag screws in this direction. Okay, but like this, right? Perpendicular to the fracture plane at this particular level. So let's just confirm with the X-ray that we are actually happy with the way this looks. Can we bring the machine? Don't use the hand to turn it. Use the proximal piece so you don't put any torque on your reduction. And because we made the incision a bit more proximal than our marks, we got fooled by the X-ray a little bit. We can use this to actually put the plate, yeah, at the instrument. Internally rotate. Come a bit more this way now. Oh, that's good, let's try there. Picture there, please. Okay, so it looks good in the top, but not so hot at the bottom, right? So let's just work on that a little bit. So that tells you a couple of things. A little short, you probably... Yeah, yeah. So let's just release this, right? Yep. And let me just pull that up, right? Okay, but before you do that, let me just look at the fracture here. Oh, I see, you're a little bit displaced anteriorly. So, ready, pull, internally rotate a little bit. Stand by, lemme put my finger there. Still a little off. Yeah, but it's starting to look a touch better. Let me see here. Internally rotate for me. Hold on. There you go, lift up there. Let go, let go, let me... Yeah, that feels better. Let me feel that. Okay, let's just secure that. Don't put the other one yet, hold it in gentle internal rotation. Let's take another look. Let's see how it looks now. So we are trying to do this without disrupting the periosteum. A little bit this way. Or you can peel the periosteum and take a look at the whole fracture and make that touch easy, but that beats the purpose. See, it looks better already, push in, there you go. Picture there, okay, that's acceptable. Okay, so let's do a lateral view just to make sure that it's okay. Always check your images orthogonally. I've been occasionally cheated by... The other way, please. Yeah, all the way down, there you go. Lock it there for a second for me, yeah, okay. So now, lower your machine, actually, shoot there. See where we're at, okay, internally rotate a lot more, but don't displace it. Yeah, that's it, yeah, careful with it. Picture there, okay. Could you go distally and lower your machine some more? Okay, picture there. All right, so we are very good. Okay, you can come out. Now the trick is let's put a couple of lag screws without commuting the fracture. Careful with this, yeah, and back out. All right. Okay. Irrigation a little bit. Let's just clean up the wound a touch.
CHAPTER 5
And we're gonna start with a 3.5 drill, please. Maybe in a little bit of extension, is there any way to get that bad, or? Nah, that's okay. Okay. Sometimes the hardest thing is to not be fooled by what you think is gonna be better. This is a very, very good reduction. Yeah. Yes. Okay, so before we get too carried away, let's just plan our screw. We're gonna put one up there and one down there. Okay, 3.5, drill whenever it's ready. Thank you so much. So, the principle of the lag screw, right, is you put a larger hole on the proximal cortex and then a smaller hole in the distal cortex. So when you pass the screw, it's catching only in the distal cortex and the headless screw works as a lagging technique. So, Dr. Rodriguez, do you drill the pilot hole and the proximal piece first, and then the hole hole, or go through both and then the proximal? No, I do this one, right, like this to get my direction in the most... Okay, can we switch that to a 2.5? And now I take the 2.5 guide and I kinda shove it in there, right? Right, and then it's coaxial, so that I know it's coaxial and I can just hit it. Okay, we'll take the depth gauge, please. And we're gonna put our first screw. Now, when you're doing this, you gotta be a little bit careful you're not messing with where you're gonna be putting your plate, right? So that looks like a 28. That strike me as a little bit short for an oblique screw. Let's take a quick X-ray. It looks like it's gonna be a 28, guys, and we'll do it by hand. Non-locking screws. everything should be non-locking for this case, hopefully. Picture there, please. Okay, that sounds appropriate, okay, back up a little bit. Right, so now this is the size of the other thread. So this just sinks in. There's not - right? And it only catches threads on the other side, right? And then, if you look at the fracture plane, if you're deferring a true lag effect, when you squeeze it, you occasionally see a little bit of blood coming out from it, right? So this is a very, very nice and solid screw. Okay, so that's one, right? Why don't we do another one like right here? So we'll take this, we'll take the same jig, please. 3.5 again? Yeah. 3.5, yeah. And this spiral type of pattern, do you need to put the lag screws in two different directions? The drill guide, please. Well, ideally you wanna put the screw at a point where it's perpendicular to the fracture plane at that point. Because we are doing it without really being able to see the whole fracture, you're kind of taking a bit of a guess, but you kinda know the fracture is like this. So I'm gonna guess this screw is gonna be a bit like this, right? And this is just a guesstimate of where it should be. Right? If you could switch that to a 2.5. And then you put this... Right? And that's how you assure coaxial alignment. So 2.5 distal hole, 3.5 proximal hole. And then we put our second screw in, and that's our repair. That's what we need to do. So now the plate is just protecting those two screws, right? That's why it's called a neutralization plate because it neutralizes the stresses on the screws. It's a depth gauge, it's a little bit worn out, but the depth gauge reads like a 26. Let's take a 26, please. So if we did this properly, then, you know, we can - we kind of screw that in there, right? So now it's coaxial. If we did this properly, we should be able to take that clamp, and the fracture should remain aligned, right? So I'm gonna clamp this down. I'm gonna reinforce this one at really - a little touch. Okay, let's take the clamp and, hopefully, it won't go boing and fall apart, but... Nice, okay, so now we put our finger and we feel a very nicely reduced fracture. And now very gently we're gonna rotate the leg and let's take a picture, confirm that the fracture looks good and then we're gonna put a plate across it. Picture there, please. Again. All right, so you can, actually, don't back out yet. Let's go to the plates now and let's kind of gauge where our plate - what size plate we're gonna need.
CHAPTER 6
So these have a... These don't have a laterality to them, right? They're all the same. So let's pick a generous one. Let's go with these two. Okay, so, internally rotate. And now we're gonna just do a shadow. Picture. Picture. Picture. Okay, come a little bit more distal. Picture there. Picture. Internally rotate more, please. A lot more, like don't be shy about it. Picture. There you go, right, so this plate, picture there. Picture. Could you make a mark on the distal, oh, we have it, it's right at the joint line, so it's perfect. So this will be a great plate. Go proximal, now see how proximal this plate goes. Picture. That's a bit overkill. So we can probably do the slightly shorter one, which is this one here, right? Probably better with her total knee also than... Yeah, yeah, exactly. So let me just template this one. Picture. Picture. Go distally. Picture there. This will more than suffice. Can I get the next shorter one? Picture. Picture. Yeah, this will be fine. Okay, you can step out for a second, thank you. So the next step is to slide the plate up, you know, and I guess we could slide it in this direction, right? Since we take advantage of the big gap we did, but we're gonna have to open it here anyway. So can I take a 15 blade and you can just open that just enough to slide the plate. So just that part there. Just from there to there. Come, come a little bit in this direction. Yeah, that's great. Excellent. Bovie and little forceps, please, Adsons. Great, great, that's more. So here. Dissecting scissors, please. The one thing I always end up doing is lacerating the saphenous vein. But welcome to, right, so we just, again, always supraperiosteum, right? So there's that here, buzz that for me. Buzz again. Thank you. Ah, of course, I missed it, buzz it. Okay, freer, please. Scissors back. It's all right. So we make a little bit of room, right? And then slide the plate up, please, and grab it there. Awesome. All right, can I take the Kocher again? Need a little bend in our plate. No, I have it. I have it here. Yeah, the Kocher is great. Here, I'll grab it here. There you go. Right. Okay, so now we have to find the perfect position for the plate. And it's a little bit more anteromedial than what you would think. Come in with the C-arm, please. And internally rotate right there. Picture there. Okay, a little bit more distal. Picture there. Okay, so it's two prox. Let's just go more that way, that makes more sense. Picture. Uh, too much. Picture there. Internally rotate some more, like a lot more. Picture. Can you center your machine so the ankle looks, yeah, picture there. Feels a little bit disappointing in the way it's fitting. Let's go out a little bit with this. And let's move it a bit more anterior. See if we can go a little bit more anterior. Picture there. Back up, I need to play with this a touch. It usually fits really nicely. Internally rotate more for me. Thank you. Hmm. Internally rotate. All right, let's just take a guess. What would happen if we put it... Here? Can you come in with this C-arm for one more - lemme stand on this side 'cause I'm going to press it in like this. All right, picture there. Okay, that's what we're gonna do, right? So it's gonna mold. It's gonna mold up in a minute. Yeah. Okay, back up. Yeah. So let's take then a 2.5 drill, guys. We're gonna just do one screw here. Power again? Power is good for this one. This is not a lag one, so I don't care so much. And that's a bit long. So let's take a 26. Yeah. So, you put your finger there and make sure that plate's not too posterior, too anterior. 26. Thank you. Pull that out, guys. Okay, handheld screwdriver. Thank you, so now we're gonna... We are looking at this and feeling, making sure it's not inappropriately prominent in any particular spot. Okay, let's take a picture now, see how it looks, and now you would - super, there you go, you kind of get it in the perfect lateral contour. Okay, let's get a picture. Okay, nice. Go a little bit more distal. Picture, okay. Back away. So I'm looking at this and I'm trying to decide if it's worth moving it proximally one hole. Can I have the freer, please? Let me just feel here. It's not gonna be prominent, it's gonna be okay. And we are missing that hole. And we got a little bit of prominence from that screw head over there. See how it's overlaying the plate? Yeah. So let's just go with this. Let's take another drill, please. This one? Yeah. We're gonna try to secure that distal part here. Can you guys gimme a little retraction there? A little rectangular right-angle retractor. Yeah, just on the skin, so I can get one screw in there so I can anchor it distally so we know that we're above the joint 'cause that's our mark. And we're gonna go a little perpendicular to the plate. This is back to you, I'll take the depth gauge. Pull a bit harder on that side. Thank you. Okay, let's go, ooh, that's a generous one. That sounds right, let's go with a four. Let's go with a 38, in power. So, for this plate, we need like three and three. The plate prevents too much torque going to the original two screws. Thank you. Handheld. A little bit of retraction there. Okay, that makes me happy there, it's not very proud. Let's go up here. How far are we heading, so we got like... So if we do one, two... Why don't you skip two, put one here. Let's see how far the plate goes. Yeah, actually do this one. Why don't you guys... And just drill it straight in. Yeah, yeah, yeah. Depth gauge, please. And you're gonna put a screw in power in a minute. It's a skinny bone. Measures at... Just start with a 22, please. 22. Yeah. Don't slam it down all the way just by... All right, handheld screwdriver, please. And then we're gonna get the 2.5 drill back one more time. Don't kill it, just a finger plus. Yeah, a finger plus is enough. Just enough to put the plate down, right? 2.5 drill, please. And then we'll do one more. Let's see if we can, can you go - here, lemme just get you a little bit more... Okay, get that last one there. Nice and perpendicular. Go ahead. Measure that. Try to do it down, right, with one hand and then it hooks and then you bring down, so it's really a 26, 28 - 24, please. So whenever it doesn't go in right away, it's because you're not in the right angle. So go ahead. Go ahead. Okay. Okay, that's three there, let's get a couple here. If you'll excuse me, I'm gonna - let me see. So we got this. This is great. Let me feel how, maybe we can get this one. Can you come in with the C - with the X-ray machine for a little bit? Hold in internal rotation. Yeah, picture there. That's very nice. So let's do one distal to that and one proximal and that should be it. Okay, can you go all the way proximal to see how far proximal we are with the screws and the plate? Picture there. All right, that's great, okay, you can back out now. Thank you. We'll take the drill, please. 2.5 drill. Yeah. And we know this is, we're getting a little bit close to the ankle, so we're gonna just aim it a little bit more up now. Let's go with a 42, please. And we're gonna get it through here, I think Through here? Yeah, let's just see if we can do it. So we have one. One, two, right? Yeah, let me just extend it. Can I take a 15 blade? There's no... Actually, no, let me see, hold on. So, one. Do we have a second one there already? Over there. Oh, I see. Okay, so this is easy. Drill. I will take it without the guide. Without the guide. Let's go with a 36. Can you put it like this? Come in with the machine, please. Picture there. Picture. Let's go with a 34. Yep. 34. Thank you. To make sure that we have enough size there to put the screw head. 15 blade. Okay. All right. That's it, let's give it a little irrigation. Let's get a couple of final pictures in AP and lateral. And let's see how it looks. Here's these instruments back to you. Now that it's fixed, we can move it from both sides. Picture there. Center a bit more. Picture there. Nice, save that, go a bit more distal. Picture. Save that, internally rotate for me. Picture there, thank you. Save that, okay, let's go to a full lateral. A little bit more. Watch your fingers, I'm gonna press down for you. It's not all the way. Ready? Thank you. Okay, picture there. Get a bit more internal rotation. Lower your machine a touch. Picture. A bit... Picture. Go distally. Picture,. Distally. Yeah, picture there. So let me just get a good lateral. Picture. Save that. Come proximally. Picture. All right, thank you so much, you're all set.
CHAPTER 7
So we'll do just a nice closure and we can do some nylons or Prolenes and stuff. And... What's all that? Just Bovie. Can I have a sponge, please? I think it's nice and - yeah. All right, let's get some sutures. Let's run a 2-0 Monocryl, and then we'll do 2-0 nylons on the surface. Yep. For this one? For this one I'll just put one 2-0 there and then a couple of nylons. So when we splint her, make sure she gets a little pocket there, right? You guys have any questions? Pretty straightforward. And an alternative, we don't do very often tibial shaft plating. It's either IM nailing, or it's part of a pilon or something that you end up plating. How many lags? How do you decide how many lag screws you need? Oh, I just kinda estimate it just to make sure we span the fractures somewhat okay. And we are gonna be very protective of her. So a couple of lag screws and plate with three screws done above and three below. So just get a very deep one and then go straight to nylons. I would just do something straightforward like this. Just catch it. Oh, just a big one, got it. Just a big one, right? Okay. You got it. Like this. Mm-hmm. And then close it there, and then go to 2-0 nylons, and then do interrupted 2-0 nylons. So that's that, the next - a little deeper. A little deeper, right? That's gonna leave a knot, very superficial. So look at this one, how deep this one goes, right? So what you wanna do is you wanna just - don't be shy. Just grab it deep. Just like something like this, right? This is just to get a little bit of tissue over the plate. Notice how we put the incision anteriorly, right? Yeah. So you don't have to be suturing over a plate. And now you can go straight to the 2-0 nylons. You want simple? Yeah, cut them both. And now put 2-0 nylons there. You can do inverted mattresses, so that the skin's a little bit nice. Not too tight. Okay. All right, this is usually when I scrub out.
CHAPTER 8
So, we completed the case. It was an uneventful case. It went very well. We decided to perform a reduction of the oblique fracture with traction manipulation and application of reduction clamp. We then applied two lag screws in a standard manner, and then applied a medial neutralization non-locking plate with about two or three screws proximally, and two or three screws distally just to protect the lag screws. We were able to slide the plate from distal to proximal and secure it with a good anatomic alignment and without compromising the proximal knee replacement in any way.