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