Tibia

Closed Tibial Fracture

Epidemiology

 

Most common long bone fracture

 

Aetiology

 

Young patients / sports

 

Elderly / simple falls

 

MVA - often compound

 

Anatomical Classification

 

Proximal

- proximal metaphysis

 

Shaft / Middle

 

Tibial Midshaft Fracture

 

Distal

- distal metaphysis

 

Tibial Fracture AP

 

Tscherne Soft Tissue Classification

 

Grade 0

- nil ST injury

 

Grade 1

- superficial abrasion / contusion

- ST injury from pressure from within

 

Grade 2

- deep contusion / abrasion

- due to direct trauma

 

Grade 3

- extensive contusion and crush

- subcutaneous tissue avulsion

- severe muscle injury

 

Issues

 

Acceptable alignment

 

No scientific data

- can probably accept a reasonable amount of deformity

- up to and including 10o without risk knee / ankle OA

 

Usually don't accept this

 

Operative v Non operative

 

Littenberg et al JBJS Am 1998

- meta-analysis of 19 papers

- non operative prevents infection

- ORIF more likely to result in union

 

Sarmiento 1000 patients closed treatment

- 60% lost to follow up

- non union rate 1.1%

- 10% short > 1 cm

- 5% > 8o varus

- comminution longer to unite

- intact fibula more rapid union but increased risk angular deformity

 

IMN v cast

 

Hooper et al JBJS 1998

- IMN more rapid union, less malunion and earlier RTW

- improved outcome when > 50% displacement or angulation > 10o

 

Puno et al Clin Orthop 1986

- 200 closed tibial fractures

- IMN union 98%, malunion 0%, infection 3%

- cast 90%, malunion 4%

 

Advantages cast

- no infection

- no knee pain

- no hardware to removed

 

Advantage IMN

- faster union

- reduced non union

- reduced malunion

- earlier ROM

- able to weight bear early

 

Non Operative Treatment / Plaster Cast

 

Indications 

 

Low energy injury

Minimal ST injury

Stable fracture / minimal / acceptable displacement

 

Acceptable

 

Coronal < 5o

Sagittal < 10o

Rotation < 10o

Shortening < 1cm

> 50% apposition

 

Technique

 

Gavity assist over edge of bed

Application SL initially

Extend with knee slightly flexed

 

Union rate 

 

90%

 

Tibial Shaft Fracture Non Operative Treatment BeforeTibial Shaft Fracture Non Operative Treatment After

 

Operative Treatment

 

Options

 

1.  IM Nail

2.  Plate

3.  External Fixation

 

1.  IMN Nail

 

Tibial Midshaft Fracture IMN APTibial Midshaft Fracture IMN Post op

 

A.  IMN Tibial Shaft

 

Locking

 

Provides rotatory stability

- required with spiral / comminution / metaphyseal

- may not be necessary with transverse fractures

 

Reaming

 

Larsen et al J Orthop Trauma 2004

- RCT of reamed v unreamed

- significantly longer time to union in unreamed

 

Reason

- reaming also bone grafts fracture site

- large nail provides greater stability

 

SPRINT trial JBJS Am 2008

- multicentred trial of over 1000 tibial IMN

- demonstrated a possible benefit for reaming

 

B.  IMN Proximal tibial fractures

 

Issue

 

High incidence malunion

- typically valgus 

- flexion / procurvatum

- posterior translation of distal segment

 

Proximal Tibial Fracture Poorly Nailed

 

Reason

 

Standard medial and anterior entry points

- mismatch to distal canal 

- canal becomes triangular

- pushes fracture into the above deformities

 

Surgical Points

 

1.  Change entry point

- match entry point to distal IM canal

- lateral and posterior

- in line with lateral tibial spine

- through or lateral to PT

- entry with knee semi-extended

 

2.  Blocking screws

- also lateral and posterior

- functionally narrow IM canal

- on concave side of deformity

- same positions as entry point

- posterior in proximal segment

- lateral in proximal segment

 

C.  IMN Distal tibial fractures

 

Distal Tibial FractureDistal Tibial Nail APDistal Tibial Nail Lateral

 

Design

 

Distal tibial nails

- multiple distal screws

- some within 5 mm of end of nail

- usually 2 medial-lateral and 1 AP

 

Technique

 

Most important is to centre guide wire over talus

- in lateral and AP

 

1.  Use finger reduction tools and pass across fracture site

2.  Use temporary external fixator

3.  Pins in distal tibia / calcaneum to control distal fragment

4.  Plate fibula

5.  Blocking screws

 

2.  ORIF with plate

 

Indications

- metaphyseal / periarticular fractures

- tibial fractures in children

 

A.  Midshaft tibial ORIF

 

Tibial Midshaft PlateTibial Midshaft Plate Lateral

 

Risk

- poor skin / blood supply / muscle cover

- high risk of wound breakdown

- must strip bone to apply plate

 

Technique

- minimally invasive

- indirect reduction techniques

 

Complications

 

Nonunion

- excessive soft tissue stripping

- inability for fracture to compress

 

Distal Tibial ORIF Nonunion

 

B.  Distal Tibial ORIF

 

Indications

- too distal to nail

 

Technique

- may need initial external fixation

- hold reduction

- enable swelling to reduce

- ORIF as per tibial plafond fracture

 

Distal Tibial Fracture DisplacedDistal Tibial Fracture External FixationDistal Tibial Fracture ORIF

 

3.  External fixation

 

Indications

 

Contaminated wound

Vascular injury

Damage Control Orthopedics

Segmental bone loss - Ilizarov

 

Technique

 

Unilateral

- 4 or 5 mm half pin

- predrill to decrease thermal necrosis

- 2 near fracture and 2 far from cortex

- 2 bars / close to skin (2 cm)

 

Complications

 

Compartment syndrome

 

5 - 15 %

- pain from nerve ischaemia first symptom

- pain with passive stretch first sign

 

Normal compartment pressures

- > 30 mm Hg less than DBP

- < 30 mm Hg

 

Infection

- 3%

 

Delayed / non union

 

SPRINT trial JBJS Am 2008

- incidence of non union of 4%

 

Malunion

 

Most common in proximal and distal tibial fracture

 

Anterior Knee Pain after IMN

 

Most common complication

 

Vaisto et al J Trauma 2008

- RCT of paratendinous v transtendinous nail insertion

- no difference in incidence of knee pain

 

Nail removal

- resolves in 1/2 after removal of nail

- improves in 1/4

- no improvement in 1/4

 

 

Complications

Infected Tibial Nonunion

Diagnosis

 

History of infection post op

Chronic non healing draining sinus

Non responsive to oral ABx

Non union

 

Investigation

 

Inflammatory markers

- persistantly raised

 

Xray

- non union

 

CT

- confirm non union

- look for sequestrum / dead bone

 

MRI

- abscess

 

Culture sinus fluid

 

Management Options

 

Manage patient factors

- cease smoking

- maximise nutrition

- optimise medical care for co-morbities

 

1.  Ilizarov Technique

 

A.  Remove metal work / IMN

- take multiple cultures

 

B.  Ream / Irrigate +++

 

C.  Apply Ilizarov

 

D.  Manage non union

 

Option 1

- fibular osteotomy

- acute compression over next 10 days

- wait bear as tolerated

- watch for union

 

Option 2

- excise dead bone / non union

- acutely shorten and compress distally

- proximal corticotomy and bone transport

 

E.  Treat Infection

 

Appropriate IV ABx 6 weeks

Monitor inflammatory markers

 

Case 1

 

12 months of persistant sinus drainage

- nail removed

- Ilizarov applied with fibular osteotomy and compression of non union

- 6/52 IV Abx

 

Infected Tibial Non Union XrayInfected Tibial Nonunion CT

 

Infected Tibial Non Union Ilizarov APInfected Tibial Non Union Ilizarov Lateral

 

Case 2

 

Persistent Infected Nonunion post distal tibial nail

- nail removed

- irrigation +++

- ilizarov frame with immediate weight bearing

- union obtained, infection eradicated

 

Distal tibial infected non union with Ilizarov APDistal tibial infected non union with Ilizarov Lateral

 

2.  IM Abx rod

 

A.  Remove Metal work / Ream and Irrigate

 

B.  Make Abx rod

- use chest tube with guide wire in it

- pour PMMA with Abx (3G vanco, 3G Fluclox)

- cut off plastic sleeve

- insert rod

 

C.  Treat infection

- 6/52 of appropriate Abx

 

D. Definitive management of non union

- return at 6/52 for exchange nail / Ilizarov / BG

 

 

 

 

Segmental Bone Defects

Causes

- acute trauma

- resection of dead / contaminated bone

- resection infected bone

- resection infected non union

 

Options

 

1.  Acute shortening

- up to 1 cm

 

2.  Autologous non-vascularised BG

- up to 3 cm

 

3.  Bone transport distraction osteogenesis

- up to 10 cm

 

4.  Free vascularised fibula transfer

- up to 12 cm

 

5.  Bulk structural Allograft 

 

6.  Amputation

- 10 - 30 cm

 

Acute shortening

 

Advantage

- allows healing to begin immediately

- improves stability

- relaxes soft tissues

- may allow primary closure

 

Disadvantage

- create LLD

- can address at later stage

 

Autologous bone grafting

 

Timing

- 6 weeks

 

Disadvantages

- slow and variable incorporation

- not ideal for large defects

 

Donor site

- posterior iliac crest

- enough for 4 cm defect

 

Approach

- traditionally posterolateral for distal & middle tibia

- may need to raise muscle / free flap

- determine which way pedicle is running

- if to anterior tibial artery, posteromedial

- if to posterior tibial artery, anterolateral

 

Technique

- debride all avascular scar

- recanalise medullary canal for blood supply

- longitudinal troughs in cortex with burr to bleeding bone

- pack in BG, overlapping cortical bone by at least 1 cm

 

Bone Transport Distraction Osteogenesis

 

Technique 1

- proximal metaphyseal corticotomy

- 5 day latency period

- 1 mm/day distraction

- bridge diaphyseal segment

- bone graft docking site at second OT

- await consolidation (2 x transport times)

 

Technique 2

- acute shortening

- proximal leg lengthening

 

Free Vascularised Fibula Graft

 

Technique

- fibula segment 4cm longer than defect

- allows overlap 2 cm each end

- must leave 5 cm fibula distally, 7 cm fibula proximally

- vascular anastomosis performed

- secured with screws and external fixator

- early change to plate fixation

 

Issues

- technically demanding

- bone needs to hypertrophy

- risk of fracture

 

Results

 

Cavadus et al Plastic Recon Surg 2010

- 38 free fibula grafts for defects > 4cm

- one graft was lost due to vascular reasons

- all healed

- 3 stress fractures

- time to union 5 - 9 months

- time to FWB 9 - 14 months

 

 

 

Tibial Malunion

Distal Tibial Malunion

 

Case 1

 

Distal Tibial Malunion APDistal Tibial Malunion LateralDistal Tibial Malunion CTDistal Tibial Malunion Correction

 

Case 2

 

Distal Tibial Malunion

 

 

Tibial Nonunion

Definitions

 

Delayed union

- difficult to define

 

Nonunion

- US FDA

- 9/12 since injury

- 3 consecutive months with no signs union

- when the fracture has not healed in what you would expect to be a normal time period

 

Types

 

A.  Hypertrophic

- abundant callous

- adequate blood supply, insufficient stability

 

Tibial Hypertrophic Nonunion

 

B.  Oligotrophic

- minimal callous

- still have adequate blood supply

- due to inadequate contact between fracture surfaces

 

Tibial Oligotrophic Nonunion

 

C.  Atrophic 

- no callous

- deficient biology, adequate stability (too adequate)

 

Factors

 

1.  Injury factors

- displacement

- bone loss

- comminution

- segmental fractures

- high energy

- compound

- soft tissue injury

- fibula intact

- anatomy i.e. scaphoid, tibia

- vascular injury

 

2.  Patient factors

- malnutrition

- smoking

- diabetes

- alcoholic

- immunosuppression

- medications

- Paget's

- renal osteodystrophy

 

3.  Surgeon Factors

- fracture left displaced

- fracture left distracted

- excessive soft tissue stripping

- infection

- nil reaming

 

Diagnosis

 

Clinical

- continued pain with weight bearing

- > 3/12

 

Investigations

 

Xray

CT

 

Surgical Options (After excludIng infection)

 

Dynamisation

Exchange nailing

Compression plating

Posterolateral bone grafting

Ilizarov technique

Adjuncts - US

 

Dynamisation

 

Indications

- well aligned fracture

- no significant bone loss

- early < 3/12

 

Advantages

- simple, day surgery

- minimal risks / complications

 

Results

- ill defined / variable

- may achieve union in 50%

 

Technique

- take out screws furtherest from fracture

 

Exchange nailing

 

Contraindications

 

1.  Bone defect

- less likely to heal if > 50% cortex missing for > 2cm

- combine with posterolateral bone graft

 

2.  Malalignment

 

3.  Presence of infection

- may achieve union but

- up to 25 % risk of disseminated infection

 

Technique

 

Remove old nail

- ream +++

- insert at least 1mm larger nail

- routinely send reamings for culture

- no preoperative ABx

 

Results

 

Court- Brown et al JBJS Br 1995

- union rates of 90% first attempt

- 100% after simple repeat

- Higher than expected rates of infection

- likely incidence of infected tibial nail not recognised preop

- i.e. indolent infection

- recommend no ABx preop and always send reamings for M/C/S

- 6/52 ABx post op if any microbes grown in lab

 

Issues

 

1.  Fibular Osteotomy

- nil need

- only if fibular malunion preventing tibial compression

 

2.  Locking

- only lock if distal or proximal fracture

 

Compression plating

 

Disadvantage

- higher infection rate

- cannot weight bear

 

Indications

- periarticular fractures

 

Cancellous Bone grafting

 

Results

- 87 - 100% union rates

 

Cancellous bone graft

- osteoinductive

- osteoconductive

- osteogenic

 

Anterolateral approach

- poor skin healing

- limited amount of bone graft

 

Posterolateral approach

 

Indication

- middle and distal thirds tibia

 

Technique

- patient prone or lateral

- incision medial to fibula

- between FHL and peroneal tendons

- elevate FHL and soleus taken off tibia

- debridement non union

- tissue sent for MCS

- create troughs in bone segments

- apply bone graft

- close fascia over BG and drain

 

Posteromedial approach

 

Indication

- proximal tibia

 

Ilizarov

 

Indication

- infection

- malunion

- acute shortening for skin loss

- bone transport for large segmental defects

 

Advantage

- allows compression

- allows immediate weight bearing

 

Adjuncts

 

US

 

Results

- proven to improve acute tibial fracture union rates

 

Advantage

- non invasive

 

Disadvantage

- expensive

- machines $5000

 

PEMF / Pulsed Electro-Magnetic Frequency

 

Disadvantage

- 2 surgeries to implant and remove wires

 

Complications

- wire fracture

- infections

 

Results

- 80% union

 

BMP

 

Friedlaender et al JBJS Am 2001

- tibial IMN with established non union

- as effective as autologous BG in achieving union

- 80%

 

Govender et al JBJS Am 2002

- early treatment in open fractures with IMN

- multi-centred trial

- IMN wth BMP v IMN alone in open fracture

- recombinant BMP 2 on absorbable collagen sponge at time of wound closure

- prospective randomised trial

- increased union rate

- less secondary interventions

- less infections

- faster wound healing

 

 

 

 

 

Ilizarov

Ilizarov Frame Proximal Tibia Clinical Photo

 

Indications

 

Poor soft tissues

- prohibit ORIF

 

Non union

 

Infected non uniion

 

Malunion / deformity

 

Bone loss / bone transport / LLD

 

Concept

 

Concept is known as flexible stability

 

Ilizarov Frame

- controls torsion and shear well

- allows axial compression and controlled micromotion

- this improves bone healing compared to standard external fixation

- tensioned wires tend to loosen over time and improve this situation with further loading

 

Can compress / lengthen

- lengthen and shorten struts

- allows compression of non union

- allows distraction osteogenesis of corticotomies

 

Components

 

1.  High tension wires

- straight or olive

- 90 - 130 kg

- 90o to each other

 

Olive wires

- used to aid indirect reduction

 

Tension

- fix one end, tighten the other

 

Offset wires from rings

- using posts

 

2.  Pins

 

Use in conjunction to wires

- never at same level as each other to avoid stress riser

- 90o to each other

- 4, 5 or 6 mm

- connected to ring via rancho cubes with centering sleeves

 

At least 2 planes of wires / half pins in each major bone segment

- very normal to use 1 tensioned wire and two HA coated half pins

- if have 3-4 wires / half pins can remove 1 (i.e. from loosening or infection) without loosing stability of construct

 

3.  Rings

 

Various sizes

- always need extra room posteriorly

- 2-3cm space to skin circumferentially

- proximal ring open posteriorly to allow flexion

- always 2 level fixation in each level for control

- can be one ring, but wires & half pins above and below

 

Stability

 

Techniques

- spread wires

- thicker wires (1.5-1.8)

- increase number of wires

- closer to fracture site

- increase tension

- smaller rings (only 2cm gap)

- olive wires

 

Wire placement

 

Anatomic Safe Zones

 

Aim is to avoid NV structures

- start on side containing critical structures

- push in to bone, drill through cortices

- wet gauze square to stabilise wire

- tap through soft tissue on other side

- muscles on maximus stretch to prevent impalement

- parallel to each other and to ring

- two rings in each segment

 

Proximal Tibia

 

Structures at risk

- CPN
- popliteal artery and tibial nerve

- saphenous nerve

 

Wires Proximal to TT

- safe arco degrees

- 3 wires

- one wire anterior to fibular head angled anteriorly

- one wire through fibular head straight across posterior tibia

- one wire through medial posterior tibia angled anteriorly

- creates a triangle of bone between wires

- always 10 - 15 mm distal to joint line to avoid proximal joint capsule

- can supplement one wire with two half pins below (HA coated) in the medial cortex

 

Wires Distal to TT

- safe arc 140o

- not safe to go through fibula

- direct wire transversely

 

Schatzker 6 Proximal TibiaIlizarov Proximal TibiaIlizarov Proximal Tibia Lateral

 

Distal Tibia

 

Structures at risk

- SPN

- DPN and anterior tibial artery

- posterior tibial artery and tibial nerve

- saphenous nerve

 

Wires

- one wire through fibula head angled anteriorly

- one through posterior medial tibia, angled anteriorly

- one straight across

- again supplement with half pins above and below

 

Ilizarov Distal Tibia ClinicalIlizarov Distal TibiaIlizarov Distal Tibia Lateral

 

Complications

 

Good pin site care is aided by avoiding loosening

- pin site complications are frequently related to loosening

 

Pin site infection

 

Reduce by

- subcutaneous (don't go through muscle)

- away from zone of injury

- adequate skin incisions

- predrill to avoid thermal necrosis

- manually insert pins

- HA coating

- regular pin site cleaning 

- early oral Abx

 

New self drilling pins are designed for motorised insertion

- avoids problem of "wobble " with hand insertion

 

HA coating

- improves fixation and decreases infection / loosening

 

Tapered pins

- increase preload and decrease loosening

- cannot back the pin up or become loose

 

Pin site care

- motion of skin is most deleterious

- leave a compressive dressing intact for 1 week

- simple daily showers with soap sufficient

 

Pin site infection

- must remove if loose

- oral Abx

- more regular cleaning

- topical bactroban (mupirocin)

 

Soft tissue impalement

 

Effects

- loss of motion

- scarring

 

Prevention

- check ROM intraoperatively

- position joint in neutral

 

Late Malunion / Refracture

 

Dynamise frame / remove struts

- allow patient to weight bear in frame

- should be non painful

 

 

 

Open Tibial Fractures

Management

Definition

 

Tibial facture with break in skin

- open wound communicating with fracture or haematoma

 

Patient is immediately at higher risk of deep infection

 

Diagnosis

 

Wound continuously oozes dark red fracture haematoma

 

Epidemiology

 

Up to 1/4 of tibia fractures open

 

Gustilo and Anderson Classification

 

Grade 1

- wound < 1cm

- usually inside out

- minimal muscle contusion

 

Grade 2

- skin laceration 1-10 cm

 

Compound Tibial Fracture Grade 2 Clinical Photo

 

Grade 3a

- > 10 cm wound, able to be closed primarily

 

Grade 3b

- require skin graft procedure for coverage

 

Compound TibiaCompound Tibia

 

Grade 3c

- vascular injury requiring repair

 

Management

 

Immediate / ED Management

 

EMST / ATLS

- assess and manage entire patient

Assess neurovascular status

Assess wound

- size / site / contamination

- photos very useful to show plastic surgeons

- will it close primarily / will it need plastic surgery

Appropriate Antibiotics

- as per Gustilo Classification

ADT

Wound management

- irrigation

- betadine dressing

Stabilise fracture

- POP

Wound Debridement < 6 hours

 

Surgical Technique

 

Extend wound

- debride contaminated tisue

- 1 mm skin edge excision

- debride subcutaneous tissue 

- deliver and debride bone ends

 

Assess muscle by 4C's

- Colour

- Consistency

- Contractility

- Capacity to Bleed

 

Bone

- remove avascular fragments unless very large or critically important

- avascular bone in continuity with vascularized bone can be kept

 

Washout

- pulse lavage to decrease bacterial contamination

- 9 litres

- photos

 

Wound management

- close if able without soft tissue tension and clean

- if needs SSG / muscle flap / free flap

- alert plastics immediately

- needs closure within 5 days for good outcome

 

Skeletal Stabilization

 

A.  Cast

- increased non and mal union in cast groups

 

B.  Temporary unilateral external fixator

 

Indications

 

1.  Vascular repair

- apply swiftly

- place out of way of vascular repair approach

 

2.  Highly contaminated wound

- inappropriate for metal work

- multiple debridements / skin closure

- eliminate infection

- delayed  definitive management

 

3.  Multiple injuries patient / Damage control orthopedics

- temporary external fixator

- convert to nail day 5

 

C.  Tibial nail

 

Indications

- fracture configuration suitable for nailing

 

Reaming

- of benefit in closed fractures

- may be no difference in open fractures

- as the ST injury worsens the benefits of reaming decreases

 

Swiontkowski JBJS Am 2008

- SPRINT trial

- no difference in outcome in compound fractures between reamed and unreamed nails

 

Bhandari et al JBJS Br 2001

- systemic review of treatment for open tibial fractures

- compared unreamed nails and external fixators

- unreamed nails decreased reoperations / superficial infections / malunions

 

D.  Ilizarov frame

 

Indication

- bone defects which will need addressing

 

Soft Tissue Envelope

 

Godina Yugoslavia 1986

- 532 patients free flaps

 

Gp 1 -  within 72hrs

Gp 2  - 72hrs - 3/12

Gp 3  - 3/12 - 12.6yrs (average 3.4 years)

 

  Flap Failure Infection Union
Group 1 0.75% 1.5% 7 months
Group 2 12% 17.5% 12 months
Group 3 9.5% 6% 29 months

Management of Soft Tissue

 

Definitive coverage within 7 days

 

Type 1, 2, 3a close with DPC

 

Type 3b

- 94% will require plastics

- 71% require flap cover

 

Skin Cover Options (see separate article)

- SSG if muscle present over wound

- proximal third gastrocneumius local muscle flap

- middle third soleus muscle local flap

- distal third / gastrocneumius or soleus damaged - free gracilis muscle flap

 

Management Bone defects

 

Priniciple is to decrease dead space

 

ABx beads

- may decrease infection from 16% to 4% (OTA)

- prevent haematoma and scar

- can place flap over top

 

Can place segmental Abx cement

- new French technique

- at 6/52 there is a periosteal sleeve about the cement

- aids in bone grafting techniques

 

Delayed bone reconstruction options

- see Complications / Segmental Bone Loss

 

Union Rates

 

Court-Brown JBJS 1991

 

Type 1

- good union rates

 

Type 2, 3a

- high union rates but slower

- 6 - 7 months to unite

- deep infection 3.5%

 

Type 3b

- union time 1 year

- infection rates 17-23%

- not affected by reaming

- not affected by nail v external fixator

- very dependent on ST coverage

 

Court-Brown

- a lot of effort has gone into assessing the mechanics of fracture management

- it is the treatment of ST that governs prognosis

 

Indications for Amputation

 

Absolute indications (Lange) with arterial injury

1.  Crush injury with warm ischaemia > 6 hours

2.  Anatomic division of the tibial nerve

 

Scoring Systems

- MESS

- NISSA (nerve, ischaemia, shock, soft tissue, age)

- shown not to be predictive

 

Leap Study

- plantar parasthesia non predictive of outcome

- doesn't predict function of tibial nerve

- many will recover over time

 

See Principles of Trauma / Amputation

 

Complications

 

Non-union

 

No progression of union over 3/12

Rule out infection

 

Options

1.  Dynamise

2.  Exchange nail

3.  Bone Graft

4.  Fib Osteotomy

5.  Ring fixator

 

Deep Infection

 

Options

 

1.  Reamed exchange nail

 

2.  Excision dead bone and necrotic tissue / Ilizarov frame

- elimination dead space

- ST coverage

- appropriate Abx

- delayed bone grafting

Skin Cover Options

Basic Concepts

 

Proximal tibia

- gastrocnemius local muscle flap

- gracilis free muscle flap if gastroc damaged

 

Middle tibia

- soleus local muscle flap

- gracilis free muscle flap

 

Distal tibia

- posterior tibial fasciocutaneous local flap

- gracilis free muscle flap

 

Distal Tibia Skin Graft

 

Hip / Thigh

- TFL musculocutaneous local flap

 

Heel

- FHB / Abductor Hallucis Longus

- dorsalis pedis fasciocutaneous local island flap

- gracilis free muscle flap

 

Types of coverage

 

1.  Split skin grafts

 

2.  Local flaps

- muscle (gastrocneumius / soleus / T Anterior / EDB)

- musculocutaneous (gastroc / TFL)

- fasciocutaneous (dorsalis pedis /

 

3.  Free flaps

- muscle

- fasciocutaneous

 

1.  SSG

 

Indication

- on bed of healthy muscle

- must not be infected

 

Technique

- graft taken with harvestor

- set desired thickness

- usually from anterior thigh

- meshing increase coverage

- stitched to rim of wound

- pressure dressing applied

- takes 5 - 7 days to take

 

2.  Local Flaps

 

A.  Muscle Flaps 

 

Advantage 

- high blood supply 

- deliver ABx to fight infection

- excellent bulk for eliminating dead space

 

Types

 

Type 1 

- single pedicle, easiest to transfer

- tensor fascia lata, gastrocnemius

 

Type 2 

- one or more dominant pedicles, plus minor pedicles

- soleus

 

Type 3 

- 2 dominant pedicles

 

Concepts

 

The muscle flap mobilises about the vascular pedicle, not the muscle itself

 

Preserving the neuro pedicle can be disadvantageous

- muscle twitching can compromise the flap

- however this can be advantageous i.e. in bracial plexus surgery

 

These never have an independent blood supply and are always dependent on the pedicle

- can raise the flap

- must be aware of and preserve pedicle

- check old notes

- plastics review

- ultrasound

 

Gastrocnemius flaps

 

Types

 

Lateral and medial

- Workhorse of the leg

- Cover between the knee prox tibia

- Need to check sufficient muscle bulk and that muscle has not been damaged in accident

 

Medial 

- most commonly used

- close to anterior tibia & larger

 

Lateral 

- can use, but must remove fibula and tunnel under anterior compartment

- putts pedicle at risk

 

Blood supply

- each head is supplied by a single sural artery 

- branch of the popliteal artery just below the joint line

- need only do angio if severe trauma, knee dislocation or previous vascular procedure

 

Soleus

 

Type 2 flap

- Useful for the middle third of the tibia

- More difficult to raise as must beware the posterior tibial artery

- Muscles can easily be damaged by the tibia in high velocity trauma

 

Tibialis Anterior 

 

Occasionally used if not too damaged

 

EDB

 

Local to ankle

 

B.  Musculocutaneous flap

 

Definition

- skin is taken also to extend the flap

- SSG used to cover skin defect of donor site

- Gastrocenumius / TLF

 

TFL

- TFL, skin and deep fascia

- Pedicle is branch of lateral femoral circumflex

- Used for hip and thigh

- Need SSG to skin defect

 

C.  Fasciocutaneous flap

 

These have independent blood supply after 2 weeks

 

Posterior tibial artery flap

- Distal Tibia but greater than 10 cm from ankle

- Based on Great saphenous vein for drainage

 

Dorsalis Pedis Island Flap

- Used to cover heel

 

Sural artery flap

 

3.  Free Flaps
 

Concept

- taking tissue with vascular pedicle 

- transferring it to a distal site and re-anastomosing it

- select flaps that have a long pedicle for ease of reimplantation and positioning

 

Results

- 95 - 98% success with good surgeons

- Nil evidence that smoking or age affect flap

- CRF / DM / atherosclerosis do

 

A. Muscle

 

For when muscle is required to bony cover or to fill dead space

 

Gracilis

- For defects 10 - 15 cm

- Based on medial circumflex artery

- Reasonable thin

 

Latissmus dorsi

- Workhorse

- For larger defects up to 25 x 40 cm 

- Based on thoracodorsal artery

 

Rectus Abdominus

- Less commonly used as hernias are a problem

 

Serratus anterior

- Used for small defects

 

B. Fasciocutaneous

 

For when skin cover only is required, not muscle bulk i.e. over ankle joint

 

Radial free flap

- Workhorse flap

Taylor Spatial Frame

Taylor Spatial FrameTSR Clinical Photo 2

 

Indications

 

Deformity correction

 

TSF Deformity Correction Proximal Tibial Fracture Preop

 

Technique

 

Apply proximal and distal rings

- choose size

- 2 cm from skin all around

- leg will often swell

- most often compression is posterior

- can use an open ring proximally to aid knee flexion

 

Apply proximal rings

- Centre / Master Tab anterior to tibial crest

- important for calculations

 

Apply Distal ring

 

6 x adjustable struts

- come in 3 lengths (short / medium / long)

- need to ensure that are long enough for any correction

- otherwise will have to adjust strut later

- numbered 1 - 6

- no 1 always to right of proximal strut

 

TSR Clinical Photo Struts

 

Intra-operative Correction

- can perform

- new computer program

- struts can be of different lenths

- i.e. the rings do not have to start perpendicular to shaft

 

Record numbers of each strut

- important for computer calculation

 

TSR Strut Measurements Pre Correction

 

Post operative Xray Measurements

 

Xray of entire tibia and rings

- xray centred on proximal tab of proximal ring

- AP and Lateral all in one film

- the entire diameter of the rings must be on the film

 

Set reference fragment

 

Proximal tibia

- usually the proximal fragment is reference fragment

- distal fragment is moving fragment

 

TSF Reference and Moving Fragment

 

Opposite for Distal Tibial Fractures

 

Set Origin / Corresponding Point on AP and Lateral

 

Origin

- reference fragment

 

Corresponding point

- on moving fragment

 

TSF Origin and Corresponding Point

 

Measure AP and Lateral View Axial Frame Offset

 

The tibia is not in the centre of the rings

- usually anterior

- need to tell computer where the proximal fragment is in reference to the rings

 

TSF AP View Frame OffsetTSF Lateral View Frame Offset

 

Estimate Rotatory Offset

 

If Proximal Ring Tab not centred over anterior border of tibia

- need to clinically estimate the difference

- i.e. 5o

 

Characterise the skeletal deformity

 

6 measurements required

 

AP View Angulation + Translation

 

TSF AP View Angulation and Translation

 

Lateral View Angulation + Translation

 

TSF Lateral View Angulation and Translation

 

Axial Translation (Shortening)

 

TSF Axial Translation

 

Axial View Angulation

 

Clinical

- is the foot externally rotated

- if so, how much

 

Total Residual Correction

 

Enter details

- ring size

- strut length

- reference fragment / origin

- frame offset

- 6 measurements

 

Tell rate of correction

- usually 10 days to 2 weeks

 

Computer will calculate correction

- assumes correct to neutral

- print daily strut changes requires

 

Example

 

TSF Proximal Tibial Fracture Pre CorrectionTSF Proximal Tibial Fracture Post Correction

 

TSF Proximal Tibia Union APTSF Proximal Tibia Union Lateral

Tibial Plafond

IssuesSevere Tibial Plafond

 

Complex / High energy injuries

 

Management of soft tissues critical

- restore length with external fixation

- await swelling to dissipate

 

Restoration of alignment / Joint surface imperative

 

Outcome guarded

- can still develop arthritis with good joint surface restoration

- initial injury to chondral surfaces
 

Definition

 

French for Pestle

 

Fracture of tibial weight bearing surface due to axial compression

 

Epidemiology

 

35 - 40 years

Males 3 x

 

Up to 50% incidence of associated injuries

 

Aetiology

 

Rapid axial load

- very high energy

 

Anatomy

 

Soft tissues very poor

- thin skin

- absence of muscle and adipose tissue

- lack of deep veins

 

Especially vunerable over anteromedial tibia

 

Reudi Classification

 

1.  Undisplaced

2.  Displaced Simple

3.  Displaced Complex

 

CT scan

 

Critical to planning

- helps to guide surgical approach

- minimise dissection

- main fracture configuration

- plating configuration

 

Tibial Plafond External Fixator

 

Management

 

1.  Soft tissue algorithm

 

Management of the soft tissues is the key to a good outcome

 

Long delays

- wait until swelling down

- wrinkled skin, blisters resolved

- wait 3 weeks plus if needed

- operating early can be a disaster

 

Spanning external fixation

- holds out length

- helps soft tissues recover

- patient can mobilise

- allows surgery on planned elective list

 

Tibial Plafond Pre External Fixator APTibial Plafond Pre External Fixator Lateral

 

Tibial Plafond Post External Fixator APTibial Plafond Post External Fixator Lateral

 

2.  Surgical Algorithm

 

A.  Restore fibula length

- holds fracture out to length

- prevents fracture malunion

 

B.  Varied surgical approach

- anterolateral / anteromedial / posterolateral

- depends on fracture configuration

- posterolateral if large posterior tibial fragment requiring buttress

 

C. Reduce articular surface

 

D. Restore bony alignment

 

1.  Anterolateral +/- medial plate

- percutaneous proximal fixation with indirect reducture

- restore alignment and length / provide stability

 

2.  Ilizarov Frame

 

E.  Graft any defect

- often as a delayed procedure at 6 weeks

 

Techniques to minimise complications

 

1.  Long delays until definitive surgical treatment using initial spanning external fixation 

 

2.  The use of small, low-profile implants 

 

3.  Avoidance of incisions over the anteromedial tibia 

 

4.  The use of indirect reduction techniques minimizing soft tissue stripping / MIPO

 

5.  Careful surgical management of the soft tissues at all times

 

Surgical Technique Plating

 

Position

- supine on radiolucent table

- IV ABx

- tourniquet for 2 hours then release

 

ORIF fibula

- holds fracture out to length

- via posterolateral incision

- need wide skin bridge from anterior incision

 

Anterior skin incision

- small longitudinal incision centred over jont line

- 10 cm long

- usually anteromedial (between T Ant and EHL)

- must be 7 cm from posterolateral incision

- expose distal tibia

- minimise stretch on wound edges at all times

 

Anatomical reduction joint surface

- open fracture site

- open joint

- washout haematoma

- apply femoral distractor to view joint surface

- pins in tibia and calcaneus

- examine talar dome using periosteal elevator

- open joint and inspect

- ORIF small osteochondral fragments with modular hand screws / 1.5 - 2 mm

 

Attach metaphysis to diaphysis

- anatomically contoured low profile locking plate

- MIPO techniques

- anterolateral L shaped plate via anterior wound

- small incisions proximally to insert screws

- 4 cortices above fracture

- small medial incision to insert medial plate percutaneously

 

Early ROM

 

Bone graft defects at 6/52

 

Complications

 

Wound

 

Devastating wound complications

- 0% to 6% in four recent series

- with best practice

 

Tibial Plafond Wound Breakdown

 

Deep Infection

 

Stiffness

 

OA

 

Excellent results rare

 

Fair to good are the norm

- develop AKJ OA over time (50%)

- related to cartilage injury at time of trauma

- AKJ arthrodesis rare

 

Studies

- most have some pain

- most return to work

- cannot run or play sports

- pain continues to improve for long times (up to 92 months)

- delay arthrodesis

- x-ray appearances not always related to clinical picture

 

Case Examples

 

Example 1

 

Fracture configuraiton

- characteristic Tillaux fragment

- otherwise lateral column mostly intact

- large medial fragment / medial column disruption

 

Plan

- small anterolateral approach

- joint reduction and cannulated screw from Tillaux fragment medially

- medial percutaneous plate

 

Tibial Plafond CT AxialTibial Plafond CT SagittalTibial Plafond CT Axial

 

Tibial Plafond ORIF APTibial Plafond ORIF Lateral

 

Example 2

 

Severe plafond

- large medial fragment

- characteristic Tillaux / syndesmotic fragment

- articular fragments driven up into joint

- both columns disrupted

 

Plan

- anterolateral approach

- use femoral distractor

- remove fragments from joint

- restore articular fragments with screws

- anterolateral plate (separate proximal incision for proximal screws)

- percutaneous medial plate (leg was ultimately too swollen, percutanous screws inserted)

 

Severe Tibial Plafond CT CoronalSevere Tibial Plafond CT SagittalSevere Tibial Plafond CT Axial

 

Severe Tibial Plateau Post Op

 

Case 3

 

In this case can alter incision

- anterolateral

- anterolateral plate only required

 

Tibial Plafond Fracture

 

Case 4

 

Distal tibial fracture with fibular fracture

- fibular ORIF for additional stability and improved alignment

 

Tibial Plafond with Fibular Fracture PreTibial Plafond with Fibular Fracture Post ORIF

Tibial Plateau

 

Schatzker Classification

 

1.  Lateral Spilt 

- seen in young patient

- lateral meniscus can be incarcerated in fracture

 

Tibial Plateau Schatzker 1

 

2.  Lateral Split Depression

- often seen in young patients with high energy injuries

- vary in severity

 

Tibial Plateau Joint DepressionSchatzker 2 Split DepressionSchatzker 2 Split Depression CT

 

3.  Lateral Depression 

- central depression usually seen in elderly

- have to create lateral cortical window in order to elevate fragment

 

Tibial Plateau Depression

 

4.  Medial plateau & intercondylar eminence 

- high velocity injury associated with ACL / LCL / CPN injury

- can be low injury / osteoporotic and often unreconstructable

 

Schatzker 4 Tibial Plateau

 

5.  Bi-condylar + intact metaphysis

- unstable

- requires ORIF

 

Schatzker 5 Bicondylar0001Schatzker 5 Bicondylar0002Schatzker 5 Bicondylar CT

 

6  Bi-condylar + metaphyseal fracture

- fracture separating metaphysis from diaphysis

- highest incidence of vascular injury

 

Schatzker VISchatzker 6 Schatzker 6 CT

 

Epidemiology

 

Most common is Type II / split depression

- 80%

 

Type IV

- medial plateau involved

- 10 - 20%

 

Type V, VI

- both condyles involved

- 10 - 20%

 

Anatomy

 

Medial plateau larger than lateral

- medial is concave in sagittal plane (golf tee)

- Lateral is convex & more proximal (golf ball)

 

Creates 3o of varus proximal tibia

 

Knee Normal AP

 

Lateral plateau is covered by meniscus

- tolerates incongruity better than medial plateau

 

Normal posterior slope

- 10o

 

Pathology

 

Lateral plateau more commonly fractures

 

1.  Medial plateau more resistant to fracture

- due to its larger surface and increased weight bearing

- thicker stronger subchondral bone

- any fracture of medial plateau indicates high energy 

- high incidence of soft tissue complications & poor outcomes

 

2.  Valgus alignment of leg

 

Type of fracture

 

1.  Young people splits / wedges

2.  Older people joint depression

 

Associated Injures

 

1.  56% incidence of ligamentous instability 

- ACL and LCL seen with medial plateau fracture

 

2.  20% incidence meniscal injury

 

3.  CPN

- again seen with medial plateau fracture

 

4.  Compartment syndrome

- seen in type 5 and 6

 

5.  Popliteal artery damage

 

Factors affecting outcome

 

1.  Step > 5mm

 

Blokker et al Clin Orthop 1984

- >5 mm step 0% G/E

- <5 mm 75% G/E

- < 2 mm 85% G/E

 

2.  Alignment

 

Rasmussen Acta Orthop Scand 1972

- valgus > 10o 80% OA

- valgus < 10o 14% OA

- accept only < 5o varus /  valgus

 

3.  Meniscus

 

Jensen et al JBJS 1990

- 70% OA with meniscectomy

 

4.  Instability

 

Honkonen J Orthop Trauma 1995

- M/L instability > 10o 70% OA

 

Indications for surgery closed fracture

 

1.  Step > 2mm

2.  Malalignment

3.  Mensical injury

4.  ML laxity

 

Management

 

Examination

 

NV examination

Soft tissue examination

- Tscherne / closed soft tissue injury classification

- Gustillo / open soft tissue injury classification

Exclude compartment syndrome

 

CT scan

 

Sssess joint line

- predetermine fracture pattern before fixation

 

Temporary Spanning External Fixation

 

Knee Spanning Ext Fix

 

Tibial Plateau Temporary External Fixator APTibial Plateau Temporary External Fixator Lateral

 

Indications

- open fracture

- complex pattern / shortening / malalignment

- poor soft tissues / extreme swelling

 

Advantages

- pulls out to length with ligamentotaxis

- allows soft tissues to settle / swelling resolves

- subsequent surgery easier and safer

 

Construction

- 2 x 5 mm half pins anterior / AL femur

- 2 x 5mm half pins anterior tibia far from incision

- apply under II guidance / reduce / apply traction

- 2 x anterior rods

- slight flexion

 

Definitive Management

 

1.  ORIF

 

Tibial Plateau ORIF

 

Timing

- blisters epithelialised

- skin wrinkled

- 2-3 weeks

 

Set up

- prone on radiolucent table

- knee flexed over bolster or triangle

- tourniquet, antibiotics

- remove frame, scrub leg and apply sterile dressings to pin sites to remove from operative field

- some surgeons leave frame on to aid reconstructive surgery

- may need to use femoral distractor

 

Approach

 

1. Lateral longitudinal incision

- split ITB proximally

- open anterior fascia distally

- elevate tibialis anterior from tibia

- incise coronary ligament

- elevate capsule and ligament via 1 vicryl stay sutures

- inspect joint and lateral meniscus via varus force

 

2.  Posteromedial approach

- 1 cm from posterior border tibia

- between medial gastrocneumius and pes anserinus

- buttress or antiglide 4 hole DCP / T plate

- may be indicated for Schatzker IV / V / VI

 

Technique

- elevate and restore joint line (may need cortical window and punch)

- compress with bone reduction forcep

- stabilise joint line with 2 x 6.5 mm cannulated partially threaded screws

- check II

- restore alignment via application anatomically contoured 4.5 mm locking plate

- can use MIPO if required (long fracture, Type VI)

- often use BG or substitutes under depression fractures laterally (Norian)

 

Stability

- must assess at end of operation

 

Specific

 

Type 1

- can reduce and screw percutaneously

- beware trapped lateral meniscus

- consider arthroscopic inspection initially

- difficult to see because of haematoma 

- also risk of compartment syndrome so need careful fluid management

 

Tibial Plateau Schatzker 1 Percutaneous ScrewsTibial Plateau Schatzker 1 Percutaneous screws Lateral

 

Posterolateral Tibial Plateau Fractures

- fracture in posterior half of lateral tibial plateau

- very difficult to access / transfibular approach

- expose / release / protect CPN

- predrill fibula head

- osteotomy above CPN

- reflect fibular head posteriorly on biceps / LCL attachments

- ORIF lateral plateua

- fibular osteotomy secured with 6.5 mm partially threaded cancellous screw

 

Type IV

- medial plate alone

- address lateral instability

 

Schatzker 4 Medial Plate0001Schatzker 4 Medial Plate0002

 

Type V

- single lateral plate

- double plating with medial buttress / LCP / T plate

- may wish to reduce lateral side first for anatomy

- apply medial plate second for stability

- may be a coronal split in medial plateau or TT requiring AP screws

- may need ORIF ACL bony avulsion

 

Tibial Plateau Bicondylar ORIF APTibial Plateau Bicondylar ORIF Lateral

 

Tibial Plateau Type VTibial Plateau Type V ORIF APTibial Plateau Type V ORIF Lateral

 

Type VI

- long locking plate minimally invasive with locking jig

- proximal lag screws

- ensure correct alignment

- often use small medial buttress plate

 

Tibial Plateau Schatzker 6 ORIF APTibial Plateau Schtazker 6 ORIF LateralSchatzker 6 ORIF APSchatzker 6 ORIF Lateral.jpg

 

2.  External Fixation

 

Indications

- poor soft tissues

- compound

 

Technique

- pins 14 from joint surface

- use olive wires to compress fracture fragments

 

Schatzker VI Ilizarov

 

Rehabilitation

 

Hinged Brace

NWB 8 weeks minimum

 

Complications

 

Collapse / Malunion

 

Tibial Plateau Collapse Malunion Tibial Plateau Collapse Malunion

 

Tibial Plateau MalunionTibial Plateau Malunion 2

 

Option

 

1. Distal femoral varus osteotomy and fresh osteochondral allograft

 

Lateral Tibial Plateau MalunionValgus MalunionDFVO and osteochondral allograft

 

2. TKR

 

Tibial Plateau OA TKR0001Tibial Plateau OA TKR0002

Tibial Stress Fracture

EpidemiologyTibial Stress Fracture

 

Athletic / high impact exercises

 

Aetiology

 

First described in ballet dancers (Burrows 1956)

- tension side of bone / lateral side

- progression to complete fracture has been well documented in athletes

 

Signs

 

Point tenderness

- lateral aspect of tibia

 

Over time develop bony lump

 

X- ray

 

Often narrow medullary canal & thickened periosteum

- proximal third in adolescents

- runners typically at junction of middle and distal 1/3 

 

Tibial Stress FractureTibial Stress Fracture 2

 

Dreaded black line / fracture

 

Tibial Stress Fracture

 

 

 

Posteromedial Tibial Stress Fracture

 

On compression side

Better prognosis for healing

 

Posteromedial Tibial Stress Fracture

 

Biopsies 

 

Granulation tissue, fibrous vascular periosteum, underlying new bone formation

 

DDx

 

Osteoid Osteoma

Ewings

Osteogenesis Imperfecta

 

 

 

Issues

 

Can take a long time to heal

- up to 1 year

 

Can fracture

- which can go on to non union

 

Management

 

Non operative Management

 

Options

 

PTB / Rest

Ultrasound

ECSW

 

Operative Management

 

Options

 

Bone graft

Percutaneous drilling

IMN

Anterior Plating

 

IM Nail

 

Chang et al 1996 Am J Sports Med

- five cases of chronic tibial stress fractures

- army recruits with minimum 1 year non-op treatment

- reamed IM nail

- 3 proximally locked, 2 percutaneous corticotomies

- 1 lost to follow up

- 2 excellent results (unlimited pain free running)

- 3 good results (occasional pain with vigorous exercise)

- conclusions: safe, effective / no need to lock proximally / corticotomy not needed

 

Varner et al Am J Sports Med 2005

- 7 athletes treated with IM reamed nail

- united by 3 months

- return to sport by 4 months

- one patient developed bursitis at nail insertion site which settled with HCLA

- one patient developed a distal tibial traumatic fracture which healed non operatively

 

Anterior Plating

 

Borens et al J Orthop Trauma 2006

- 4 world class female athletes

- treated with anterior tension band plate

- no complications

- all healed and return to full sports at 10 weeks