Kyle F. Dickson, M.D. M.B.A.

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Kyle F. Dickson, M.D. M.B.A.
Professor Baylor College of Medicine Southwest
Orthopaedic Group, Houston, Texas
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Proximal Tibia Fractures

• Kyle Dickson MD, MBA
• Professor of Orthopaedis Baylor College of
  Medicine, Houston
• Southwest Orthopaedic Group

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Goals of Surgery

• Anatomical reduction of the articular fracture
  (absolute)
• Anatomical alignment of the limb (relative)

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Case

• 55 yo boat captain on the Mississippi River
• Crushed leg between ship and 3,000 lb sheet metal
  roll Grade IIIC tibial plateau and distal femur
  fracture
• 10 days later with the worst tibial plateau and
  distal femur Ive seen. This patient needs a
  above knee amputation.

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Viable Treatment Options

• Closed reduction percutaneous screw fixation
  and/or fine wire fixation
• Arthroscopic visualization with closed reduction
  and fixation
• Open reduction internal fixation with standard or
  locked plating
• Tumor prosthesis

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Mechanism

• Mechanism of injury is important when considering
  treatment options, timing and associated injuries

ForceMass x Accelleration KE1/2MV2
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Evaluation

• Plain radiographs
• AP, lateral, and obliques of knee
• AP and lateral of entire tibia
• 10 degree caudal view
• CT scan indications
• MRI
• SOFT TISSUE

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DC

• 32 yo ped vs mva
• Bilateral open tibias, open book pelvis, splenic
  and liver laceration
• SBP 80

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Lang, CORR 1995

• Proximal Third Tibia Shaft Fractures
• Should they be nailed?

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Lang (cont.)

• 32 fractures (22 open 10 closed)
• 5 reamed nails in closed fractures
• 27 unreamed nails

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Lang (cont.)

• 84 gt 5 angulation
• Valgus 56 gt 5 28 gt 10
• Apex anterior 59 gt 5 22 gt 10

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Lang (cont.)

• 25 loss of fixation
• 2 patients required osteotomy
• 4 patients re-operation for realignment

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Lang (cont.)

• 18 attendings
• RT nail - 15 bend 45 mm distally
• AO nail - 11 bend 100-140 mm distally

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TOO SICK NOT TO FIX FRACTURES
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Blood/FFP/Cryo/Plts 11 ratio !
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Timing

• Within 24-48 hours injuries most mobile
• 2-5 days may be worst time to operate
• Soft tissue good (includes lung)
• Positive fluid balance

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Damage Control Orthopaedics

• Prevent 2nd hit (MOF, MSOF, SIRS, ARDs)
• Hgb lt 8
• Base Deficit gt 5 mEq/l (pHlt7.2,lactategt2)
• Body temperature lt 33º
• INR gt 1.5

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Proximal Metaphysis

• CT scan pre-op
• Optimal Entry Site
• Maintain Reduction
• Clamp
• Joy Stick
• Poller Screws
• Unicortical plate
• Multiple Locking Screws - spread

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Problems

• Nail does not reduce the fracture and maintain
  reduction in the metaphysis
• Metaphysis good blood supply (healing potential)
  ? nail breakage through open screw holes
  (7cm-Hahn 1996)

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Proximal Tibial Fractures Problems with IM Nail

• VALGUS Angulation
• Canal larger laterally
• Medial Entry Site Contributes
• Muscle Tension of Pes Anerinus
• Eccentric Proximal Reaming
• APEX-ANTERIOR Angulation
• Nailing in Flexion
• Distal Herzog Curve
• Eccentric (anterior) Entry Point

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Poller Screws
Tighten medullary canal
Traffic Cone
Screw next to desired nail position blocks
displacement Place where you want the nail
NOT to go.
Krettek et al JBJS 81B964, 1999
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Criteria

• Main fracture line below tibial tubercle or 13mm
  above plafond
• Joint extensions from main fracture line are
  minimal or simple impactions (no plateaus and
  plafonds)

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CT Scan Proximal Distal Fractures

• Articular Involvement?
• Fx Orientation?
• Preliminary Lag Screws?
• To Plan Locking

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Spanning External Fixation

• Restores and maintains length
• Restores axial alignment of leg
• Improves position of bone fragments by
  ligamentotaxis
• Reduces further soft tissue embarrassment
• Allows outpatient treatment

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When I Use a Spanning Ex Fix for Tibial Plateaus

• Gross contamination
• Significant shortening (gt1cm)
• Subluxation or dislocation of knee
• Vascular injury
• Try to remove by 4 weeks
• Hinged ex fix?

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Principles of Spanning Ex-fix

• Put pins away from your eventual incision and
  fixation (plan to use as femoral distractor)
• Stability (pin clamps less stable)
• Dont put in hardware

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Lateral Starting Hole
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26 M s/p machine accident, grade II open Tibia fx
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Other Reduction Aids

• Femoral distractor
• Schanz pin (closed fractures away from fracture
  site)
• Interlock in extension (? pull of quadriceps)
• Unicortical plate (locking holes)

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Solutions

• Anatomical alignment pre nailing
• Center center both proximally and distally both
  on the AP and lateral both with the starting hole
  and the direction blocking pins
• No open holes next to the fracture site

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Supine Image TableLeg Support (?)
KNEE BENT gt 90
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Key Points

• Central starting hole on both the AP and lateral
• Entry point superior tibia (subchondral bone)
• Tibia reduction with pelvic clamps or unicortical
  3.5 or 4.5 plate (open wound)
• Liberal use of blocking screws

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Knee Pain

• 30-70 incidence (40 opposite knee pain)
• ? Incision length, patellar splitting vs. medial
  parapatellar

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New incision
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Semi-extended Nailing

• Suprapatellar quadriceps splitting
• 22 (4/18) knees had iatrogenic damage to
  articular surfaces of the patella and
  intercondylar notch
• Early in the study, poor technique

OTA 2010 Zamorano
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Technique (cont.)

• Canulated awl or guide pin 2-3 mm lateral to
  center tibial spines on good AP
• Lateral subchondral bone ? straight down shaft

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Technique (cont.)

• Straight reamer or curved awl proximally for 8,
  9, 10 mm
• Center guide pin proximally distally AP Lat

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Blocking Pin vs Blocking Screw
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Pearls

• Blocking screws may be used in any long bone
  nailing where the fracture extends outside the
  diaphyseal bone
• Use a guide pin (3.2mm) initially
• Place the pin where you dont want the nail to go

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Soft Tissue Complications in Treatment of Complex
Fractures of Proximal Tibia with use of the Less
Invasive Stabilization System

• OTA 2003

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Results

• 14 (7/49) soft tissue complications
• 3 free flaps
• No nonunions or malunions

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Fracture ClassificationSchatzker
Complete Articular Fractures
Parital Articular Fractures
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Universal Classification

• Type A-Extra-articular
• Type B-Partial articular
• Type C- Complete articular

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Schatzker I-IV
Schatzker V-VI
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Operative Tactic
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Associated with a Bad Result

• Instability (missed posteromedial or
  posterolateral piece)
• gt1cm articular step off (need to be perfect)
• Malalignment
• Widening of the plateau

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Incision

• Anterolateral and posteromedial
• More direct with less stripping
• Difficult to do a TKA
• Anteror and posteromedial
• Careful soft tissue, raise the meniscus
• Easier TKA incision
• Be aware of postero-medial or lateral piece

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Approaches
Posteromedial
Anterolateral
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Antero-lateral Approach
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Femoral Distractor

• Cant change a tire without a jack and cant fix
  a tibial plateau without a femoral distractor
• Visualization
• Adequate elevation of the joint
• Limb alignment (two in this case)

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Technique

• Articular reduction anatomic (start with least
  comminuted side lag screws 3.0, 4.0, and 4.5mm
  cannulated screws)
• Anatomic alignment of the limb

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Partial Articular
Schatzker I
Schatzker II
Schatzker IV
Schatzker III
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Operative TacticPartial Articular

• Aritcular Reduction
• Direct reduction Universal distractor
• Indirect reduction C-arm, arthroscopy
• Stabilization
• Interfragmentary screws
• Buttress plate
• 3.5 mm screws

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Schatzker Type I

• Split fracture
• Open vs percutaneous treatment
• Lag screws/- buttress plate

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Schatzker Type II

• Split depression fracture
• Submeniscal arthrotomy
• Elevation / bone graft
• Lag screws/buttress plate

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Surgical TreatmentSplit Depression Fractures
(Schatzker 2)
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21 year old wake boarding
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Schatzker Type III

• Pure depression fracture
• Amenable to percutaneous techniques with fluoro
  /- arthroscopy
• Metaphyseal window for elevation and grafting
• Screws beneath subchondral bone

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Surgical TreatmentDepressed Fractures (Schatzker
3)
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Elevate the depressed central fragment from
below.
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Depression pre-op
EN 31 year old
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CT articular depression
EN
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Arthroscopic findings
Medial depression
Fragment elevation
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Post-op
EN
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Schatzker Type IV Medial tibial plateau fracture
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Type IV Fractures are frequently a realigned knee
dislocation!

• Associated with
• Peroneal nerve injury 5-50
• Popliteal artery injury 13-50

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Medial Plateau
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Complete Articular
Schatzker V
Schatzker VI
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Operative TacticComplex Tibial Plateau Fractures

• Require lateral and medial stabilization of
  fractures
• Stabilization
• double plating,
• locked plating
• external fixators

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When/Why does it work better?

• Osteopenic Bone
• Metaphyseal Areas
• Comminution

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Locked Plate Problems

• Poor timing of surgery (MIS ? sooner surgery)
• Shark bite failure (longer plate, bicortical, and
  prestressed straight plate on a contoured bone)
• Cold welding with hardware removal

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Problems With Locked Plates

• Cost
• Stiffness
• Restricted screw placement and one size fits all
• Less of a reduction aid

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Evolution
Or something completely different?
You be the judge!
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Axial Load
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Conventional Plate Fixation
Patient Load
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Locked Plate and Screw Fixation
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Standard versus Locked Loading
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Bending Force
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Conventional Plate
First Screw Failure
MLJ
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Conventional Plate
Sequential Screw Failure
MLJ
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Conventional Plate
Plate/Bone Dissociation
MLJ
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Locking Plate
Threaded Head
Locked Screws are Fixed Angle Constructs
MLJ
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Locking Plate
MLJ
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Locking Plate
Catastrophic Failure Less Likely
MLJ
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When/Why does it work better?
Traditional Plating Stripped screw hole
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When/Why does it work better?
Locked Plating Stripped screw hole
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Locked Plate and Screw Testing

• Osteopenic Bone Model (Low density foam)

1.7X
1.5X
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Locked Plate and Screw Testing

• Bone Model (High density foam)

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Locked PlatingSurgical Technique
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Locking Plates

• Tapered tip ? submuscular insertion

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lt 2 months
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gt 1 year
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Biologically Friendly4 weeks post-op
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Indications

• Better fixation to prevent medial and lateral
  fixation (bicondylar tibial plateau, distal
  femur)
• Osteoporotic bone
• Really Smashed fractures

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Indications cont.

• Metaphyseal fractures
• Articular reduction maintenance

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78 yo F lt Schatzker VI Tibial Plateau
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Stabilization of Medial Fragment
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Knee in External Fixator
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6 Months Post-Op
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Double Plating Complete Articular Fractures

• Two incisions
• Anterior and posteromedial
• Wound complications acceptable
• Indications
• Displaced posteromedial fragment needs to be
  buttressed with posterior plate
• Medial articular involvement with shaft
  comminution
• Displacement of medial column

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Fixation Complete Articular

• Fragmented lateral plateau
• Simple medial plateau
• Reduce joint
• Stabilize both sides
• medial first to give landmark for lateral
  reduction

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Fixation Complete articular
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Fixation Complete Articular
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Intra-Op
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Intra-Op
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Post Op
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Posteromedial fragment
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Problems

• Soft tissue problems (coverage and infection)
• Comminution of the joint - gt10 articular pieces
  (Reconstructable?)
• Articular reduction and limb alignment

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Viable Treatment Options

• Closed reduction percutaneous screw fixation
  and/or fine wire fixation
• Arthroscopic visualization with closed reduction
  and fixation
• Open reduction internal fixation with standard or
  locked plating
• Tumor prosthesis

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Technical Considerations

• Open the joint absolute fixation maintain
  biology to shaft relative fixation
• Generally femoral articular fractures shear and
  tibial articular impact
• Direct lag screw fixation in the femur Indirect
  elevation of a bed of cancellous bone for tibial
  articular surface (under the meniscus and through
  fracture line)

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Summary

• Anatomical articular reduction -
  inter-fragmentary screws and Buttress plates for
  partial articular fractures
• Anatomic alignment - inter-fragmentary screws
  for joint and double plating or Locked plates for
  bicondylar fractures
• Double plating best when complex medial fracture
  or postero-medial fragment
• Locked plates for articular maintenace and
  cominution

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Thank You