Tibial Plafond

IssuesSevere Tibial Plafond

 

Complex / high energy injuries

 

Management of soft tissues critical

- restore length with external fixation

- await for swelling to reduce

 

Restoration of alignment & joint surface imperative

 

Outcome guarded

- can still develop arthritis with good joint surface restoration

- initial injury to chondral surfaces
 

Epidemiology

 

35 - 40 years

Males 3 x

 

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

 

OTA Classfication

 

43-B Partial Articular

43-C Complete Articular

 

CT scan

 

Tibial Plafond External Fixator

 

Critical to planning

- helps to guide surgical approach

- main fracture configuration

- plating configuration

 

Commonly 3 fracture configurations

- medial malleolus

- posterolateral fragment / Volkmann

- anterolateral fragment / Chaput

 

Tibial plafond common fragmentsTibial plafond fragments

 

Associated injuries

 

Compound wounds

 

Silluzio et al. Injury 2019

- 14 open tibial plafond fractures

- 28% deep infection

- 43% delayed union

https://pubmed.ncbi.nlm.nih.gov/31171351/

 

Fibula fractures

 

Fibular fracture tibial plafondTibial plafond fibular fracture

 

Bonnevialle et al. Orthop Traumatol Surg Res 2010

- may aid reduction

- however, may contribute to nonunion

- if fibular fracture is malreduced, can contribute to tibial malreduction and malunion

https://pubmed.ncbi.nlm.nih.gov/20851076/

 

Syndesmotic / Syndesmotic equivalent injuries

 

Syndesmotic equivalent fractures tibial plafondChaput fragment syndesmotic equivalent

 

Haller et al. J Orthop Trauma 2019

- 14/735 (2%) had missed syndesmotic injuries

- 93% of these patients developed post traumatic osteoarthritis

- syndesmotic equivalent injuries more common with Chaput (AITFL Ligament) / Volkmann fragments (PITFL) or fibular avulsion

https://pubmed.ncbi.nlm.nih.gov/30768532/

 

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

 

Technique

- ankle bridging delta frame

- two pins in the tibia away from surgical site

- transcalcaneal threaded pin placed medial to lateral

- pin in first meta-tarsal to keep foot in neutral position

 

Tibial Plafond external fixator

 

AO foundation surgical technique

https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/distal-tibia/partial-articular-split-depression-fracture/temporary-joint-bridging-triangular-external-fixation#reduction-and-fixation-triangular-external-fixation-

 

2.  Surgical Algorithm

 

A.  Restore fibula length

- holds fracture out to length

- may prevent fracture malunion

 

B. Reduce articular surface

 

C. Restore bony alignment

 

D.  Bone graft any defects

- can be done as a delayed procedure at 6 weeks

 

Surgical options

 

ORIF with plates

Circular external fixation

 

Malik-Tabassum et al. Injury 2020

- meta-analyis of ORIF v circular external fixation

- increased rate of hardware removal for ORIF

- reduced rate of osteoarthritis with ORIF

- no difference in superficial or deep injection, or secondary fusion

- no obvious difference in outcomes

- more severe injuries tended to be treated with circular external fixation

https://pubmed.ncbi.nlm.nih.gov/32430194/

 

ORIF with Plates

 

Surgical Approaches

 

Varied surgical approach

 

A. Anterolateral approach

- to apply an anterolateral plate

- indicated with valgus configuration

- anteolateral / Chaput fragment

 

Incision centred on ankle joint

- in line with 4th metatarsal

- preserve branches superficial peroneal nerve

- divide extensor retinaculum

- all extensor tendons reflected medially, including peroneus tertius

 

Anterolateral fragment and valgus injuryTibial plafondTibial plafond anterolateral plate

 

B. Anteromedial approach

- indicated with varus configuation

- large medial fragment

- medial to tibialis anterior

- can make small anterolateral incision to fix small Chaput fracture

 

Tibial plafond medial plate 1Tibial plafond medialTibial plafond medial plate 3

 

C. Posterolateral approach

- indicated if large posterior tibial fragment requiring buttress

 

Techniques to minimise complications

 

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

 

2.  The use of small, low-profile, anatomical 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 antibiotics

- tourniquet for 2 hours then release

 

ORIF fibula

- holds fracture out to length

- via posterolateral incision

- need wide skin bridge from anterior incision

 

Anterolateral approach skin incision

- 10 cm long incision centred over jont line

- 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

- can apply femoral distractor to view joint surface

- 4 mm Shanz pins in talar neck laterally, and into tibia proximal to plate

- examine talar dome using periosteal elevator

- ORIF small osteochondral fragments with small modular 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

 

Postoperatively

- elevate +++

- NWB

- early ROM

- consider bone grafting defects at 6/52

 

Outcomes

 

Bonato et al. Injury 2017

- 1 year outcome of 91 plafond injuries

- 57% return to work at 1 year

- 27% reported residual moderate to severe pain

https://pubmed.ncbi.nlm.nih.gov/28233519/

 

Pollack et al. JBJS Am 2003

- 80 patients at a mean of 3.2 years post injury

- 35% reported ongoing stiffness and pain

- 43% not working

- https://pubmed.ncbi.nlm.nih.gov/14563795/

 

Complications

 

Wound breakdown

 

Tibial Plafond Wound Breakdown

 

Deep infection

 

Duckworth et al. Bone Joint J 2016

- 9% (9/102) rate of deep infection

- associated with co-morbities, open fractures, initial external fixation

https://online.boneandjoint.org.uk/doi/pdf/10.1302/0301-620X.98B8.36400

 

Stiffness

 

Osteoarthritis

 

Harris et al. Foot Ankle Int 2006

- 79 pilon fractures with mean follow up 2 years

- 40% developed post traumatic arthritis

https://pubmed.ncbi.nlm.nih.gov/16624215/

 

Malunion

 

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


Nonunion

 

Haller et al. J Orthop Trauma 2019

- incidence of nonunion 14% (72/518)

- associated with open fractures, bone loss, and smoking

https://pubmed.ncbi.nlm.nih.gov/31094937/

 

Case Examples

 

Case 1

 

Fracture configuration

- characteristic Chaput fragment

- otherwise lateral column mostly intact

- large medial fragment / medial column disruption

 

Plan

- small anterolateral approach

- joint reduction and cannulated screws into Chaput fracture

- medial plate inserted and fixed with MIPO technique

 

Tibial Plafond CT AxialTibial Plafond CT SagittalTibial Plafond CT Axial

 

Tibial Plafond ORIF APTibial Plafond ORIF Lateral

 

Example 2

 

Severe plafond fracture

- large medial fragment

- characteristic Chaput / 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