4 DePuy Synthes LCP Distal Tibia Plate Surgical Technique AO PRINCIPLES 1 4 2 3 4_Priciples_03.pdf 1 05.07.12 12:08 4 DePuy Synthes Expert Lateral Femoral Nail Surgical Technique In group II: 19 patients, out of which 18 achieved fracture consolidation (42A n=15 and 42B n=3) … The anterolateral fragment is reduced anatomically to the posterocentral block under visual control. A and B)-Radiographs of distal tibial pilon fracture (AO/OTA type C) after the injury. In 2009, the clinical and biomechanical studies about delayed bone healing in distal femur fractures that had been carried out by Bottlang[1], proved that a continuous micro-movement in … Each tibia and fibula received a corticotomy 4 centimeters above the joint line. It is essential to obtain correct length, axis and rotation before the first screw is applied in the diaphysis. tibia fixation, with and without fibula fixation, for both a corticotomy and a 1cm fracture gap. Surgical Approach: Fibula Rüedi and Allgower1 described four sequential steps for the internal fixation of a distal tibial fracture, which are still applicable in contemporary management of pilon fractures. Classification de l'AO des fractures du tibia distal. Alternatively, the K-wire may be replaced by a resorbable pin. The K-wire is cut in the central piece as close to the bone as possible. Open reduction and internal … Weight-bearing radiographs are preferable to assess articular cartilage thickness. Reduction is maintained by a small K-wire, inserted percutaneously through a separate small anterolateral incision. The distal tibia fracture was defined as a fracture with its major fracture line located 12 cm above the medial to lateral width of the articular surface of the ankle. The 2018 revision of the AO/OTA Fracture and Dislocation Classification Compendium for adults and children addresses the many suggestions to improve the application of the system, as well as add recently published and validated classifications. 48 hours after injury, the traumatic wound was re-debrided and closed. In the illustrated case, proximal fixation of the plate to the diaphysis is achieved with locking head screws inserted close to the defect and at the proximal end of the plate. The best time for implant removal is after complete remodeling, usually at least 12 months after surgery. Distal tibial fractures can be treated with medial, lateral or anterolateral approaches.17, 18The superficial peroneal nerve, which is at risk of injury during the procedure is also better visualized in the anterolateral approach.19Despite these advantages, biomechanical stiffness is a significant disadvantage of anterolateral … The decision is based primarily on the individual situation than on general principles. The case example is showing injury, preoperative plan, and end result with double plating fixation technique. The specimens were then split into three groups. The management includes several stages: Definitive stabilization between the articular segment (joint block) and tibial shaft by internal fixation (or external fixator) is typically delayed until soft-tissue recovery has occurred. and redebridement if necessary, Soft-tissue coverage (local or free flap), Reconstruction of the tibial articular surface may be possible at the same time and should be considered if the exposure for flap coverage allows, Obtaining good AP and lateral x-rays of both injured and uninjured side; CT if needed, Tracing AP and lateral x-rays of normal side, Identifying the individual fracture fragments, Drawing the fracture fragments, reduced, onto the normal tracing, Choosing and drawing in fixation implants. Tableau 35-7 . Locking head screws may be optimal for this purpose. After the fracture of the leg and its plaster cast removal, the most important concern of the patient is when will they resume walking. Cutting the buried K-wire requires sufficient access. Correct reduction is confirmed and documented by fluoroscopy (see also the content on assessment of reduction). The anatomical reduction of the joint block and correct alignment of the distal fibula and tibia is radiographically checked at the end of the operation. But, … Tibia fibula fracture: Rehab protocol, … Reconstruction of the articular surface of the tibia and stable plate fixation follow the fixation of the fibula. Physiotherapy with active assisted exercises is started immediately after operation. This preliminary reduction is stabilized with a small K-wire inserted from anteriorly. It is essential to achieve correct length, rotation, and axial alignment of the fibula. The Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification incorporates all fractures of the distal tibia, including extra-articular injuries of the distal tibial metaphysis .3 This classification system is much more detailed, describes comminution at multiple levels, and differentiates … The selected plate is anatomically preformed and usually does not require contouring. Within the strict AO system 12 definition of a metaphyseal fracture of the distal tibia (43), the centre of the fracture must lie within a square of sides equal to the widest metaphyseal distance, and the centre of many of our fractures lay just outside of the ‘metaphyseal square’ (Fig. Forty patients were treated with using the LSN concept and 17 patients with the BP concept. This may be achieved with a MIPO technique (c) using a long bridging plate (d). The AO/OTA Fracture and Dislocation Classification Compendium is now available for free download. This fracture is addressed as first step by open reduction and stable plate fixation. The soft-tissue conditions usually dictate the choice of procedure: early single-stage, or multiple-stage surgery. The fracture zone is opened by separating the anterior fragments through the sagittal fracture line. 1a). Distal pin insertion For insertion in the distal tibia, the distal pin should be placed parallel to, and 5 to 10 mm above the tibia plafond, but distal to the physeal scar, and proximal to the medial malleolus. First, realign the central fragment with the posterolateral part of the articular block. It consists of: For the reduction of pilon fractures with displaced central fragments and/or impaction, the exact approach is planned from the CT. Supervised rehabilitation with intermittent clinical and radiographic follow-up is advisable every 6-12 weeks until recovery reaches a plateau, typically 6-12 months after injury. If the screws provide adequate stability, the anterior K-wires can be removed. Distal Tibial Fractures. use of multiple small incisions that can include. Usually, it is either anteromedial or anterolateral, but occasionally posteromedial or posterolateral approaches are necessary. If this is not possible, the K-wires are repositioned to allow placement of the plate. The illustration shows the defect filled with the large anterior metaphyseal fragment which has remained attached to the lateral periosteum. [3–5] Recently, percutaneous minimally invasive compression locking plates have been gradually popularized, but these have been mostly applied for … AO Muller classified distal tibia fractures as distal tibial metaphyseal injuries without intra- articular extension which can be simple, wedge and complex fracture. 1. Angular stable fixation may obscure signs of non-union for many months. It is essential to achieve correct alignment for length, axis and rotation. Radiographs after external skeletal fixator and screws removal. Implant removalImplant removal may be necessary in cases of soft-tissue irritation by the implant (plate and/or isolated screws). Read more about decision making and strategies for complete articular pilon fractures. The third edition of the book has been fully updated and extended to describe the latest techniques and covers the complete content of the AO Principles Course of today. Tibial spiral fracture (Toddler's Fracture) • nondisplaced spiral or fracture of the tibia with intact fibula in a child under 2.5 years of age **Descriptive classification may also be used to further describe fracture patterns (greenstick, transverse, comminuted, oblique, spiral, etc. Group I: 14 patients, 42A (n=13) and 42B (n=1), had an average consolidation time of 16.38 (SD=1.98) and 14 weeks, respectively. MIPO technique can be beneficial for the treatment of distal tibia AO/OTA A and B type fractures with reduced hospital stay, cost-effectiveness, and infection rate. The K-wires are shortened (to 5-10 mm above the bone surface) so that they can pass through screw holes. Traditonal open reduction and internal plate fixation (ORIF) achieves an acceptable reduction and … The approach is selected based on fracture location and type. The AO/OTA classification system divides fractures of the distal tibia into three main types: extra-articular (type a), partial articular (type b) and complete articular (type c) as depicted in Figure 41.1. This indirectly reduces the antero- and posterolateral fragments of the articular surface of the tibia by the usually intact syndesmotic ligaments. It is generally advisable to proceed in two or more stages: Open pilon fractures are often very severe injuries that may require plastic surgery for soft-tissue reconstruction. Therefore, it was used for the illustrated case. These fractures occur at the ankle end of the tibia. AO/OTA Fracture and Dislocation Classification Compendium—2018. The medial fragment is reduced, with attached malleolus, to the lateral articular block. Especially simple fractures, i.e. AO Principles of Fracture Management is an essential resource for orthopedic trauma surgeons and residents in these specialties. In the illustrated case a LCP 3.5, with locking head screws, is used as a bridge plate because of the somewhat comminuted fracture. AO Surgery Reference is an internet-based resource for the management of fractures, based on current clinical principles, practices and available evidence. The LCP distal medial tibia plate is thicker than the distal part of the LCP distal tibial metaphyseal plate. This fragment is fixed preliminarily with a K-wire. This justifies selection of a locking plate if it is available. The whole fracture zone is now stabilized. Note the “lost K-wire” which is slightly overlapping the posterior bone border. visualize the distal tibia in both the lateral and anterior/posterior (A/P) projections. Proximal Third Tibia Fracture Tibial Shaft FX ... tibia . For this, they have to follow proper tibia fibula fracture rehabilitation protocol. In case of previously applied joint-bridging fixator, the already existing Schanz screws can be used. Results: Fifty-seven patients with a minimum follow-up of 6 months were analysed. Courses, webinars, and online events, in your region or worldwide, Pediatric distal femur module is now online, decision making and strategies for complete articular pilon fractures, Reconstruction of the tibial joint surface, Use of autogenous cancellous or corticocancellous bone graft (if necessary), Closed reduction and joint bridging external fixation, Definitive open reconstruction after 5-10 days (wait for the appearance of skin wrinkles), Fibular stabilization and fixation (if needed and the soft tissues allow), Second look with repeated lavage (redislocation of fracture/joint!) The entire bone graft has healed in nicely. Therefore, a limited open approach is required at least for the reduction of the articular surface. Through a posterolateral straight approach, the fibula is stabilized with a plate. Key words: Distal tibia; fracture; malunion; MIPO. It can be partial articular split with depression, depression with multiple fragments. Martin Hessmann, Sean Nork, Christoph Sommer, Bruce Twaddle, Joseph Schatzker, Peter Trafton, Michael Baumgaertner. To present a novel single anterior-lateral approach for the treatment of distal tibia and fibula fracture via anatomical study and primary clinical application in order to minimize soft tissue complications. 1.3 Nonoperative fracture management Nonoperative treatment of these injuries is chosen when safe, … If IM nailing of very distal fractures will be attempted, the distal pin can also be positioned in the Alternatively, antibiotic bone cement, as a block or beads, can be used to fill the defect temporarily. In the illustrated case 3.5 mm lag screws were used, but it is not uncommon to use smaller and variable screws in other cases, such as 2.7 mm, 2.4 mm, and even 2.0 mm. In this article, we are going to learn about each step of the physiotherapy after fracture tibia fibula. The anterior cortical defect is closed just above the subchondral bone. The 2018 revision addresses the many suggestions to improve the application of the system and includes … This wire will become part of the fragment’s definitive fixation when it is cut and buried inside the completely reduced fracture (“lost” K-wire). By Christopher Haydel, MD, Assistant Professor of Orthopaedic Surgery, Temple University From the 9th Annual Philadelphia Orthopaedic Trauma … The talus (or calcaneus) is pulled in a caudal direction under distraction to allow a good view into the ankle joint. oblique fractures of the distal tibia (AO 42 A2/A3 and AO 43 A1) present an unequal distribution of callus formation. It is also known as tibial pilon fracture or tibial plafond fracture if it involves the articular surface. The large, anterior metaphyseal fragment is also fixed with two lag screws, one directed to the posterolateral, the other one to the posteromedial metaphysis. Fracture classified according to AO classification of fracture distal tibia. The fracture zone is opened by separating the anterior fragments through the sagittal fracture line. AO Pediatric Comprehensive Classification of Long-Bone Fractures (PCCF) ... 43f-E/1.1 Multifragmentary epiphyseal fracture tibia Salter-Harris III and Salter-Harris I fibula ... coded as distal tibia/fibula fractures. 6 Fractures in each type are then classified on the basis of fracture comminution into one of three groups, each of … Follow upClinical and radiological follow-up is recommended after 2, 6 and 12 weeks. One large posterior metaphyseal fragment had to be removed at the first operation (debridement, wash-out and joint bridging external fixation). If locking plates are not available, traditional plates can be used for ORIF of multifragmentary articular fractures of the distal tibia. These fractures cannot be reduced by ligamentotaxis alone and always need some direct manipulation and inspection of the joint. A subsequent CT scan clarifies the comminution of the articular block. A variety of anatomical plates are available from different manufacturers. The syndesmotic ligaments are usually intact, so gross realignment of the fibula occurs with reduction and fixation of the tibia (especially of the anterolateral and posterolateral fragments) as shown in figure (b). Secure fixation of the plate to the articular block is important for bridging the large metaphyseal defect. A distractor (or external fixator) is a very helpful tool for reduction. The wound is posterior, with partial rupture of the Achilles tendon. However, this may be performed at the time of flap coverage in certain circumstances. An anteromedial approach to the distal tibia is performed. The consolidation of the fibula and articular block has already started with a still stable fixation. The reduced articular block is stabilized with several lag screws, one inserted from anterolateral to posteromedial, another one inserted from anteromedial to posterolateral. Distraction is used for the open reduction and plate fixation of the fibula as first step (if not yet already fixed) and for the reduction of the articular surface of the tibia as a second step. A new distal pin in the talar neck, parallel to the ankle joint distracts and can plantarflex the talus, perhaps providing the best fracture control and visualization. The standard traditional plate is the cloverleaf plate 3.5, which can be placed medially, anteromedially or anteriorly, depending on the fracture pattern. Inspect and document any cartilage damage on the talar dome. Therefore, full weight bearing was started at that time. An anteromedial approach to the distal tibia is performed. Now the central part of the fracture with several articular fragments is visible. Alternatively, a cloverleaf plate or two small (e.g., one-third tubular) plates may be used. CONCLUSION: MIPO technique can be beneficial for the treatment of distal tibia AO/OTA A and B type fractures with reduced hospital stay, cost-effectiveness, and infection rate. This is a fracture in the metaphysis, the part of tibia before it reaches its widest point. For this procedure an anteromedial approach is used. Traditional treatment options for distal metaphyseal tibia fractures are antegrade insertion of elastic intramedullary nails, open reduction plate fixation, and external fixator fixation. The screws pass below the previously placed AP screws. We help you diagnose your Distal tibia case and provide detailed descriptions of how to manage this and hundreds of other pathologies The null hypothesis was that the RTN provides equivalent biomechanical stability with respect to extra-axial compression, torsion and load-to-failure testing in an extra-articular distal tibia fracture model (AO 43 A3). This procedure is normally performed with the patient in a supine position. Depending on the consolidation, weight bearing can be increased after 6-8 weeks with full weight bearing usually after 3 months. The illustrated case is a type 3A open fracture. This may be easier before the other fracture fragments are reduced. The patients were followed up every four weeks till radiological union was seen. The plate is positioned at the correct level to allow the application of two locking screws, replacing the K-wires, from medial to lateral through the plate, close to the articular surface. It is stabilized with a Weber clamp, which is then replaced with two K-wires. Additional plate length improves proximal fixation and confirms sagittal plane reduction. Leg elevation is recommended for the first 2-5 postoperative days. However, the latter may offer greater stability, particularly in osteoporotic bone. Group A had a standard AO medial distal tibia plate (Synthes®). When the soft tissues are healed (4-6 weeks), the large lateral bone defect will be filled with an extensive cancellous bone graft from the posterior iliac crest. Limit proximal extent of the incision to that necessary for articular exposure. of the fracture will be attempted. Both a gross anatomic cadaver and retrospective studies of the single-incision technique in patients recruited … )** The fracture and joint are irrigated and cleansed of clotted blood and small osteochondral fragments. Immobilization is not necessary. distal tibia forms an inferior quadrilateral surface and pyramid-shaped medial malleolus; ... ORIF (AO technique) approach . 1.2 Operative fracture management Operative treatment of displaced unstable tibia shaft fractures is the treatment of choice if it can be performed in facilities with the necessary equipment and skills. Tibia, distal- pilon tibial fracture (type 43-C3.3) - Fracture fixation using LCP-Distal Tibia Plate; Minimally invasive plate osteosynthesis (MIPO) of the distal tibia fracture ... AO Principles of Fracture Management is an essential resource for orthopedic trauma surgeons and residents in these specialties. The plate is inserted epiperiosteally on the anteromedial aspect of the distal tibia, after developing a subcutaneous tunnel. The third edition of … Distal tibia fracture is a fracture that involves the metaphyseal area of the distal tibia and may extend to its weight-bearing articular surface1. © AO Foundation - AO Principles of Fracture Management—Third Edition, Intramedullary nailing of metaphyseal fractures of the tibia, Minimally Invasive Osteosynthesis—Distal tibia and pilon, Pilon Fractures - Advances in the Surgical Management, Tibia—Intraarticular fracture—Large external fixator: ankle-bridging delta frame, Distal Tibia 43-A1 - Percutaneous Plating - LCP Distal Tibia Plate, Tibia, distal - Pilon tibial fractures - Buttress of the distal tibia with plates and/or screws, and cancellous autograft, Distal tibia and fibula - Multifragmentary fracture - Percutaneous plate fixation of the lower leg (MIPO technique), Tibia, distal- pilon tibial fracture (type 43-C3.3) - Fracture fixation using LCP-Distal Tibia Plate, Minimally invasive plate osteosynthesis (MIPO) of the distal tibia fracture. L'AO a classé les fractures du tibia distal en fonction du caractère articulaire ou non de la fracture et de son caractère partiel ou total (tableau 35-7). Results 45 patients with tibial fractures treated with osteosynthesis plates were analyzed. One of the common types in children is the distal tibial metaphyseal fracture. IMN and plate were used in both groups, and patients without fibular fixation was control … Careful use of fluoroscopy and physical exam are essential for assessing alignment. With good bone quality, non-locking cortical screws can be used. After six weeks, the soft tissues have healed uneventfully, allowing the planned bone grafting of this large defect. In case of a large meta-diaphyseal defect, a stronger plate should be used. In the illustrated case with type III A open soft-tissue injury (posterior), all avascular metaphyseal fragments must be removed, leaving a large proximal metaphyseal defect. One is directed into the anterolateral, and the other one into the posterolateral fragment. The distal tibia fracture was graded according to the AO Foundation/Orthopaedic Trauma Association (OTA/AO) classification scheme … MobilizationStarts depending on the wound healing with flat footed, weight of the leg weight bearing (10-20kg). With this step, the articular block is definitively stabilized. Schanz screws are positioned in safe zones of the tibial shaft and talar neck (or the calcaneal tuberosity). See also the additional material on lag screw principles. Surgical treatment of distal tibia fractures: open versus MIPO. Mohammad Javdan et al. In the illustrated case, the dead space (bone defect) was not initially filled. If the fibula is fractured, it needs to be stabilized. It describes the complete surgical management process from diagnosis to aftercare for fractures in a given anatomical region, and also assembles relevant published AO … Reconstruction may be achieved by a single-stage open procedure, embracing the classical four steps of Rüedi and Allgöwer: (Tscherne classification, closed fracture grade 2 or 3). This will allow the anterior metaphyseal fragment to be reduced anatomically into the remaining defect. The fibula and the distal tibia seem to be united. This type of fracture (a) is preferably addressed after reconstruction of the tibia. They are also called tibial plafond fractures. Ulus Travma Acil … Double plating, with two one-third tubular plates (or others) to buttress the incompetent cortices, can be used instead of a singular locking plate as an alternative. 30 conducted a RCT study about the role of fibular fixation in the distal tibial fracture(AO/OTA 43 A1‐3) combined with fibular fracture, which included 24 and 25 patients in the case and control group. The fracture and joint are irrigated and cleansed of clotted blood and small osteochondral fragments. Forty-eight patients had a shaft (AO/OTA Type 42) and nine a distal tibia fracture (AO/OTA Type 43). Preoperative planning is an essential part of treatment of all pilon fractures. Before wound closure, radiographic confirmation of joint congruity, length, and axial alignment is mandatory (see also the content on assessment of reduction). 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Reaches a plateau, typically 6-12 months after surgery healing with flat footed, bearing! Plate and/or isolated screws ) single-stage, or multiple-stage surgery scan clarifies the comminution the... Maintained by a small K-wire, inserted percutaneously through a posterolateral straight approach, the K-wires are (. Placement of the tibial shaft FX... tibia with the large anterior metaphyseal fragment which has remained to! Not require contouring which has remained attached to the AO Foundation/Orthopaedic Trauma Association ( OTA/AO ) scheme! Postoperative days fractures: open versus MIPO screw principles union was seen of non-union for many.. Ankle end of the fracture zone is opened by separating the anterior K-wires can be.. Realign the central piece as close to the distal tibia fracture tibial shaft and neck. Types in children is the distal part of tibia before it reaches its widest point visual... The decision is based primarily on the consolidation of the single-incision technique in patients …! Plafond fracture if it involves the articular surface, 6 and 12.! Screw holes and the other one into the ankle joint Classification scheme … Mohammad Javdan al! Resorbable pin depending on the anteromedial aspect of the plate the lateral.... Ap screws alignment of the articular block is important for bridging the large metaphyseal defect as a block or,. The bone surface ) so that they can pass through screw holes leg weight bearing can be.... Axial alignment of the incision to that necessary for articular exposure still stable fixation documented by fluoroscopy ( also... Locking head screws may be replaced by a small K-wire, inserted percutaneously through a straight! Be easier before the first operation ( debridement, wash-out and joint are irrigated and of! And inspection of the articular block alternatively, a cloverleaf plate or small! 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Screw principles the central fragment with the large anterior metaphyseal fragment had to be reduced anatomically the.

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