Tibia Plateau Fracture: Metaphyseal Defect Management after Depressed Articular Fragment Elevation

Today, we are going to talk about tibial plateau fractures & metaphyseal defect management after depressed articular fragment elevation.

Management of Periarticular fractures is based in concept of Anatomical reduction of fracture. To allow for primary healing to happen, absolute stability & rigid fixation must be attained. For that sometimes, grafting may be required in defects/gaps in the metaphyseal region.

CASE 1

Clinical Presentation:
– 60 years female.
– Slip and fall at home.
– Severe pain in right knee with restricted knee ROM and inability to weight bear on right leg.

Radiological investigation:
– X-Ray Right knee – Anteroposterior and Lateral Views

Diagnosis:
– Split Depression Lateral Tibial Plateau Fractures (Schatzkers Type 2).

CASE 2

Clinical Presentation:
– 59 years Male.
– Alleged history of Road traffic accident.
– Severe pain in right knee with restricted knee ROM and inability to weight bear on right leg.

Radiological investigation:
– X-Ray Right knee – Anteroposterior and Lateral Views

Diagnosis:
– Medial Plateau Fracture With Split Depression Lateral Tibial Plateau Fractures With Meta-diaphyseal Dissociation (Schatzkers Type 6).

CASE 3

Clinical Presentation:
– 44 years Male.
– Alleged history of Road traffic accident.
– Severe pain in left knee with restricted knee ROM and inability to weight bear on left leg.

Radiological investigation:
– X-Ray Left knee – Anteroposterior and Lateral Views

Diagnosis:
– Split Depression Lateral Tibial Plateau Fractures (Schatzkers Type 2).

CASE 4

Clinical Presentation:
– 18 years Female.
– Alleged history of Road traffic accident.
– Severe pain in left knee with restricted knee ROM and inability to weight bear on left leg.

Radiological investigation:
– X-ray Left knee – Anteroposterior and Lateral Views

Diagnosis:
– Depression Type Lateral Tibial Plateau Fractures (Schatzkers Type 3).

CASE 5

Clinical Presentation:
– 29 years Male.
– Alleged history of Road traffic accident.
– Severe pain in right knee with restricted knee ROM and inability to weight bear on right leg.

Radiological investigation:
– X-Ray Right knee – Anteroposterior and Lateral Views

Diagnosis:
– Split Depression Type Anteromedial Tibial Plateau Fractures with Tibial Eminance (ACL attachment) avulsion.

Surgical Principles and Lacunae in Management

– Principles

• Management for Periarticular Fractures is based on concept of Anatomical reduction of fracture.
• To allow for Primary Bone Healing to happen, Absolute stability and Rigid fixation must be attained.
• Use reduction technique that respects the biological principles of fixation (closed, minimally invasive or open).
• Long term predictor of satisfactory outcome post surgery is restoration of articular suface and mechanical alignment restoration of limb.
• Once satisfactory elevation/ reduction of articular surface is attained, the restored surface is stabilised with k-wire.
• The defect thus created in metaphyseal region is grafted using either Natural bone graft (Cortcocancellous bone) or Synthetic bone void filler (injectable or granules) thus providing excellent subchondral support.
• These Grafts remodel into host bone within 6-12 months.
• Finally raft screws of plate provide subchondral support and plate help in maintaining the long mechanical axis of limb.

– Lacunae

• Failure to restore articular surface anatomically may result in long term post traumatic arthritis.
• Medial tibial plateau is less forgiving as far as late consequences of a fracture because of smaller meniscus covering joint surface compared to lateral tibial plateau.

Proximal Tibia Fracture: Case Discussion

Today, we’re discussing proximal tibia fracture case. Pre-planning is the key! Sometimes for adequate visualisation of the articular surface, surgeons may prefer Arthroscopy, however a few surgeons prefer submeniscal arthrotomy for direct visualisation of fracture reduction.

Clinical History

• 46 year old male
• History of RTA
• Presented on the day of Injury
• Pain and swelling over right leg
• Co-morbidities – nil

What are the issues with this fixation?

• Fracture appears to be Split fracture of lateral tibial condyle (Schatzker Type 1).
• Articular step has not been corrected.
• Compression not achieved at fracture site.
• Hockey plate gives option of placement of only two screws at subchondral region, additional screws (outside plate) could have been used.
• Plate is not positioned properly can lead to implant prominence.
• Stress riser at plate end due to attempted bone drill.

Which factors led to these issues during fixation?

• Adequate exposure and visualization of the articular surface is of prime importance in fixation of such fractures.
• These fractures require pre-surgical planning in terms of approach required for accessing each fracture with adequate visualization of articular surface.
• Some Surgeons advocate use of arthroscopy to visualize the articular continuity/reduction whereas other group prefer submeniscal arthrotomy for direct visualization of fracture reduction.
• These fractures appear simple and one tends to have minimum visualization of lateral fluoroscopy view in a hurry of fracture fixation.

How to troubleshoot these factors?

• Pre-plan the surgery in-terms of fixation system- Internal fixation/ external fixation.(read implant manual for ideal site of placement of plates)
• Plan the necessary approach.
• Plan for bone grafting if articular depression is observed intraoperatively.
• Always temporarily fix the reduction with K wires/ screw to prevent sagging of articular fragment and Visualize the articular congruity.
• Confirm the fracture reduction in two planes.
• Use of magnified fluoroscopy view of articular surface in anteroposterior and lateral view.

Author approach

• Adequate visualization of the fracture with submeniscal arthrotomy.
• Reduction of fracture and compression is temporarily achieved with condylar compression clamps and temporary fixation with K wires.
• Countersunked Lag screw at the apex of the fracture fragment.
• T shaped plate instead of L shaped Plate as fracture line is in anterior one third tibia(lateral view)
• Longer plate for spacing out screws.
• Backup plan:
  • Additional lag screw in condylar region(prior to plate fixation)
  • Window on contralateral cortex for elevating articular surface

Tibial Plateau Fractures: Depressed Fragment Elevation Technique

Today, we’re going to talk about Tibial plateau fractures & the depressed fragment elevation technique! Anatomic reduction of the fracture & rigid fixation is the key!

CASE 1

Clinical Presentation:

• 60 years female.
• Slip and fall at home.
• Severe pain in right knee with restricted knee ROM and inability to weight bear on right leg.

Radiological Investigation:

• X-Ray Right knee – Anteroposterior and Lateral Views

Diagnosis:

• Split Depression Lateral Tibial Plateau Fractures (Schatzkers Type 2).

• Intraoperatively under image intensifier depressed fragment is identified in both AP & Lateral views.
• Medial cortical window created.
• Using curved bone punch under image guidance defect is elevated while visualizing in both AP and lateral views with gentle taps/ blows to punch.
• Once satisfactory elevation/ reduction of articular surface is attained, the restored surface is stabilised with k-wire.
• The defect thus created in metaphyseal region is grafted thus providing subchondral support.
• Finally plating done using MIPPO technique to provide lateral buttress and raft screws providing subchondral support.

X-Ray shows appropriate reduction / elevation of depressed articular fragment with buttressing of split lateral plateau.

CASE 2

Clinical Presentation:

• 39 years male.
• Motor Vehicle Accident.
• Severe pain in left knee with restricted knee ROM and inability to weight bear on left leg.

Radiological Investigation:

• X-Ray Left knee – Anteroposterior and Lateral Views

Diagnosis:

• Split Depression Fracture Lateral Tibial Plateau with Tibial Eminance (ACL attachment) avulsion and MCL Injury

• Intraoperatively under image intensifier depressed fragment is identified in both AP & Lateral views.
• Fracture split is jacked open allowing direct visualisation of depressed joint surface.
• Using punch (here a curette) under image guidance defect is elevated while visualizing in both AP and lateral views.
• Once satisfactory elevation/ reduction of articular surface is attained, the restored surface is stabilised with k-wire.
• The defect thus created in metaphyseal region is grafted thus providing subchondral support.
• Split repositioned, compressed and stabilised with K-wires.
• Finally plating done using MIPPO technique to provide lateral buttress and raft screws providing subchondral support.

• Aulsed ACL attachment/Tibial eminance stabilised, compressed ACL jig under image intensifier and fixed using Mini Tight Rope
• Split posterolateral fragment reduced, stabilised and fixed with 4mm CCS in compression mode, restoring congurity of lateral tibial plateau.
• MCL was intraoperatively found to be avulsed from its tibial attachment site, reenforced with ethibond and fixed using bone staple.
• Thus, managing fracture with associated multi-ligamentous injury in toto.

Surgical Principles and Lacunae in Management

• Principles
  • Management for Periarticular Fractures is based on concept of Anatomical reduction of fracture.
  • To allow for Primary Bone Healing to happen, Absolute stability and Rigid fixation must be attained.
  • Use reduction technique that respects the biological principles of fixation (closed, minimally invasive or open).

• Lacunae
  • Failure to restore articular surface anatomically may result in long term post traumatic arthritis.

Distal Tibia Fracture- What is the ideal treatment plan?

Should I choose Nailing or Plating technique?

A 52 YO male, visited ER with swelling & pain on the right leg. He had RTA on the same day.

What is the ideal treatment plan?

PRE-OP X-RAY

• Ideal line of management of distal tibial spiral fractures includes Computed Tomograph of the ankle joint to look for intraarticular extension of the fracture and/ or fracture of the posterior malleolus.
• Studies have demonstrated the importance of CT scan in detecting previously unreported injuries as seen on plain radiographs.

• However, in this scenario no CT scan were done, lateral view on plain radiograph demonstrated fracture line extending to intraarticular region (marked by yellow arrow)

Should I choose nailing or plating?

• In this case, Plating by MIPPO technique was used
• We have included two notable findings, which need to be addressed regarding surgical decision about the mode of fixation and their outcomes as noted in the recent studies.

• Procedure done by MIPPO technique using GPC fixLOCK Anteromedial distal tibial plate (without tab).
• Lag screw placement to achieve fracture reduction and fixation.
• Lag screw placed directly perpendicular to fracture site apart from plate construct.
• Second lag screw placed through the combi hole of the locking plate.
• We recommend treatment as per AO principles of fracture fixation with anatomical reduction of the intraarticular fracture, soft tissue handling (fracture environment), preserving blood supply, and early restoration of function.

Tibia Intramedullary Nailing – Case Discussion – PART 2

Tibia Nailing Pearls and Pitfalls

Case Discussion

Part 2

• Malalignment after intramedullary nailing of tibial shaft fractures is fairly common with prevalence as high as 36%.
• Malalignment depends highly upon variable factors such as-
  • Location of the fracture- More in metaphyseal fractures than in diaphyseal fractures
  • Fracture configuration
  • Nail entry point
  • Location of nail in proximal and distal fragment

• We have already discussed in our last segment, about the location of proper entry point and its importance.
• It is also important to achieve proper position in distal segment.
• Fractures near the middle of the shaft (isthmus) are less likely to fix in a malaligned position as the nail fits snugly whereas at the proximal and distal end of the bones the medullary canal is wider.
• Medial entry point and laterally directed nail insertion can lead to valgus malalignment.
• Slightly distal entry point in proximal fragment with the herzog bent in the nail can cause anterior angulation malalignment.

Technical tips for proper reduction of fracture using Poller screws

• The concept of Poller screw was first popularized by Krettek et al in 1999. They called the screws “poller screws” because the screws guided the nail like the “poller” (retractable bollard) traffic control devices guide traffic in Europe.
• One rule of thumb is to apply the screws on the concave side of a deformity.
• The blocking screw around the nail relieves axial strain in the fixation construct, while the interlocking screws through the nail control length and rotation

Step by step guide

• Draw a line down the long axis of the displaced, flared segment of bone.
• Draw a second line along the plane of the fracture, ensuring to bisect the first line.
• Identify your acute angles
• Place your screw in the acute angle of the metaphyseal or flared segment.
• Insert your guide wire under fluoroscopy guidance, ensuring the tip passes the correct side to ensure reduction.
• Insert your nail, which should be deflected on engaging the screw providing reduction and compression at the fracture site.
• If reduction could be improved further by the addition of a further screw, this should be placed in the acute angle nearer to the isthmus.

Take home message

• Poller (blocking) screws are an important adjunct for intramedullary nailing; aiding fracture reduction at the metaphyseal– diaphyseal junction, and offsetting deforming forces which can lead to malalignment.
• Fracture should always be held in reduced position before inserting the guide-wire and reaming. This is important because the nail will always follow the reamed tract.

Tibia Intramedullary Nailing – Case Discussion – PART 1

Tibia Nailing

Pearls and Pitfalls

Case Discussion

Part 1

• Rotation of the tibia may result in up to 15 mm of translation of the start point that may be unrecognized. Relative external rotation of the film used for nail placement leads to medial insertion sites when using the lateral tibial spine as a landmark. The fibula head bisector line can be used to avoid choosing external rotation views and thus avoid medial insertion points.
• The film that best shows the fibular bisector line is between 0° and 10° of internal rotation of the tibia.

• Too distal entry point – proximal posterior cortex breakage during operation.
• Too lateral entry point- medial displacement and varus malalignment
• Too medial entry point- lateral displacement and valgus malalignment
• Also too posterior and too anterior entry point lead to anterior and posterior displacement, respectively.

• A literature review suggests that the ideal-length implanted tibial nail would rest 5–10 mm below the proximal tibial articular surface and 10–20 mm above the distal tibial articular surface.
• This study has demonstrated lack of accurate assessment of various methods earlier documented owing to variability in intraoperative site of nail entry.
• They recommend intraoperative measurement with radiographic ruler supplemented with guidewire technique.

Understanding biomechanics of failure

• lf cortical contact across the fracture site is achieved postoperatively, most of the compressive loads are borne by the bony cortex. This makes nail a load bearing construct.
• ln the absence of cortical contact compressive loads are transferred to the interlocking screws, which results in four- point bending of the screws.
• In this case we saw an incorrect tibial nail entry with distraction at fracture site with valgus placement of nail.
• We discussed ideal entry point for tibia intramedullary nailing and its importance. Due to faulty entry the nail was placed in valgus alignment.
• We have also discussed ideal depth of insertion at proximal end and one of the cause of screw loosening and screw breakage which may be seen in these sceanrios.
• Later during our discussion, we will discuss malallignment during intramedullary nailing and its prevention- both tibial and femoral fractures.