Right Distal Tibial Oblique Fracture Open Reduction and Internal Fixation (ORIF) with Medial Neutralization Non-locking Plate

Diaphyseal tibial fractures are common injuries that are most often treated with intramedullary nailing. However, certain patient factors may necessitate alternative treatment strategies such as open reduction internal fixation (ORIF) with plates and screws. Presence of a total knee arthroplasty (TKA) in the injured extremity is one such factor. TKA is a common operation that is only increasing in popularity, and management of tibia fractures distal to TKA may be a frequently encountered clinical scenario. In this video, we present a technique for ORIF of a distal diaphyseal tibia fracture distal to a TKA that precludes intramedullary nail fixation. The fracture is fixed with lag screws and secured with an anatomically-contoured distal tibia locking-compression plate (LCP) in neutralization mode.

Diaphyseal tibia fractures are relatively common injuries, occurring in 21.5 per 100,000 people and accounting for 1.9% of all fractures in adults.¹ 17% of these fractures occur in patients >65 years old.¹ Intramedullary nailing, open reduction internal fixation (ORIF) with plate-and-screw constructs, and casting are all viable treatment options.² Reamed intramedullary nailing is the standard intervention for diaphyseal tibia fractures as this procedure involves minimal soft tissue violation while resulting in reliable union rates.³ However, choice of treatment may be influenced by specific patient factors. One such factor is presence of a total knee arthroplasty (TKA) in the injured leg. In the United States, 7.3% of adults over age 70 have undergone TKA, and the frequency with which this operation is performed is projected to accelerate in the coming years.^4,5 The presence of a TKA tibial component in a fractured tibia may block access to the ideal entry point for an intramedullary nail and increase the risk of associated iatrogenic tibial tubercle fracture. While intramedullary nailing below a TKA is a well described option in the hands of experienced surgeons when there is adequate space anteriorly, ORIF may be a preferable option if the tibia fracture is to be treated operatively and there is too little space to safely accommodate a nail.

Focused history should include the patient’s age and medical history and provide an understanding of the mechanism of injury. It is important to elicit any history of prior operations on the injured extremity such as existing surgical implants that may limit surgical options for addressing the acute injury, and prior surgical scars that may dictate the location of planned incisions. Special attention should be paid to the patient’s baseline functional status including home living situation and dependence on assistive devices for mobilization.

The patient in this case is a 59-year-old female who sustained a twisting injury to the right lower extremity during a presyncopal episode, after which she was unable to bear weight. Her past medical history is significant for prior traumatic brain injury, diabetes mellitus type 2, hypertension, depression, and anxiety. She had previously undergone a right TKA several years prior to sustaining this injury. She lives alone and is independently mobile without use of a walker or cane.

Upon initial evaluation in the emergency department, the injured right lower extremity was placed into a plaster long-leg splint for provisional stabilization. This splint uses posterior, medial, and lateral slabs to immobilize the knee and ankle while controlling rotation of the fractured tibia.

Important elements of physical exam include assessment for open wounds and a detailed neurovascular assessment. Existing surgical scars should be noted. Diaphyseal tibia fractures are at high risk of developing compartment syndrome, and serial examinations must be performed. Firmness of the anterior, lateral, and/or posterior muscular compartments of the leg, paresthesias in the foot, and pain with passive range of motion of the toes are signs concerning for developing compartment syndrome. Compartment syndrome has been reported in 11.5% of tibial fractures and is most likely to occur in younger patients under 30 years of age.⁶

In this case, the patient’s vital signs were stable. There was gross deformity of the right lower extremity with the ankle externally rotated relative to the knee. There were no injuries to the skin of the extremity. Muscular compartments of the leg were soft and compressible to palpation. She was able to move all toes without significant pain. Sensation was intact in the distributions of the superficial peroneal, deep peroneal, tibial, sural, and saphenous nerves in the foot. She had palpable deep peroneal and dorsalis pedis pulses.

Plain radiographs of the whole tibia and fibula should be obtained preoperatively. Extension of spiral or oblique fractures of the distal 1/3 of the tibial diaphysis into the distal articular surface (also referred to as the tibial plafond) may necessitate additional fixation and should be evaluated with dedicated anteroposterior (AP), lateral, and mortise (15–20° internal rotation oblique) radiographs of the ankle. In most cases a computed tomography (CT) scan of the distal fracture fragment including the articular surface is performed to evaluate for intra-articular extension. A series of CT findings in spiral distal 1/3 tibial diaphyseal fractures reported posterior malleolus fractures in 92.3% of cases, 50% of which were not apparent on plain radiographs. Posterior malleolus fracture is commonly associated specifically with a spiral distal 1/3 fracture pattern.⁷ A previous series based on plain radiographs identified posterior malleolus fractures in only 3.8% of all tibia fractures of all patterns.⁸

Radiographs in this case demonstrated a spiral fracture in the distal 1/3 of the tibial diaphysis, in the region of the meta-diaphyseal junction. Extension of the spiral fracture line towards the distal tibial articular surface was apparent on plain radiographs, and thus a CT was obtained. The CT showed extension of the fracture line to the posterior malleolus without displacement.

Left untreated, diaphyseal tibia fractures are at high risk for nonunion or malunion that would cause significant continued pain and loss of mobility. Due to the subcutaneous position of the tibia, an untreated fracture would also be at high risk of conversion to an open, or importunate, fracture. For these reasons, diaphyseal tibial fractures require active closed or open treatment in nearly all cases.

Historically, diaphyseal tibia fractures have been retreated with both closed management including casting and functional bracing and by open methods such as ORIF with plate-and-screw constructs and intramedullary nailing.

Non-operative, closed management entails initial closed reduction with placement of a long-leg plaster splint or fiberglass cast for 2–4 weeks, followed by conversion to a short-leg patellar-tendon-bearing cast or functional brace which is worn for up to 10–12 weeks postinjury.⁹ Patients return to clinic every 2–4 weeks for serial radiographs to confirm maintenance of reduction. If alignment shifts to an unacceptable degree, operative intervention may be indicated. No weightbearing is allowed for several weeks until there is evidence of robust callus formation.

In ORIF, an incision is made and dissection is carried out through the soft tissues to expose the fractured bone. The incision is centered on the fracture site and extended several centimeters proximally and distally to allow adequate exposure. The medial tibial surface is subcutaneous and can be easily exposed through an incision just medial to the tibial crest; an incision is made through the dermis and blunt dissection is used to expose the periosteum at the fracture site. Attempts should be made to preserve periosteal integrity as much as possible. The lateral surface of the tibia is exposed by incising the crural fascia just lateral to the tibial crest and elevating the anterior compartment musculature. Fractures amenable to anatomic reduction are reduced typically with multiple Weber pointed reduction clamps and fixed with a plate-and-screw construct. 3.5-millimeter (mm) and/or 2.7-mm screws may be placed using lag technique to hold the reduction and provide compression. An anatomically contoured, 3.5-mm locking-compression plate (LCP) is then placed in neutralization mode. The plate should be long enough to span the fracture and allow for at least 3 screws (6 cortices of fixation) proximal and distal to the fracture site. In very thin patients, the soft tissue envelope over the medial tibia may be so thin that the plate is very prominent or there may be too much tension for safe closure of the incision; in these cases, a plate can alternatively be placed on the lateral surface below the anterior compartment musculature. Similarly, in high-energy injuries the medial soft tissues may be too compromised to safely accommodate a closure under tension, lateral plating may be preferred. In comminuted fractures that demand a functional reduction, reduction is obtained via a combination of closed manipulation and percutaneous clamping, and a 3.5-mm LCP is applied in bridging mode. In this case, the plate may be inserted in a minimally-invasive fashion using a small incision at the proximal or distal end, slid extraperiosteally, and held with percutaneously placed screws. In either case, the leg is splinted postoperatively and weightbearing is limited for several weeks.

Intramedullary nails are inserted through small incisions around the knee. A functional reduction is obtained using a combination of closed manipulation and percutaneous clamping. A guide pin is used to identify the ideal entry point just medial to the lateral tibial spine and just anterior to the articular surface.⁹ The canal is then sequentially reamed to allow insertion of a sufficiently sized nail, typically 9–11mm in diameter. The nail is fixed proximally and distally with screws inserted through percutaneous stab incisions. Immediate weightbearing is typically allowed after intramedullary nailing.

The goals of treatment for diaphyseal tibia fractures are to restore functional length, alignment, and rotation of the fractured bone in order to return the patient to early mobility and function.

In this middle-aged, active, community ambulator, operative intervention was indicated to minimize time to full weightbearing and optimize alignment of the injured limb. The presence of a TKA in the injured tibia led to the decision for ORIF with a plate and screws over an intramedullary nail. The relatively simple spiral-oblique fracture pattern allowed for anatomic reduction of the fracture that could be fixed with lag screws and a plate in neutralization mode.

Presence of a TKA in the injured extremity may complicate placement of an intramedullary nail. Nailing around the tibial baseplate is an advanced technique and can only be safely performed when there is sufficient space between the existing prosthesis and the anterior cortex.¹⁰ The risks of nail insertion are displacing the prosthesis or causing an iatrogenic tibial tubercle fracture. If there is too little space for safe nail insertion, ORIF should be performed.

Diaphyseal tibial fractures are common injuries that may result in severe functional limitations if not appropriately treated. These fractures can be managed non-operatively with serial casting and/or functional bracing, or operatively with ORIF or intramedullary nailing. In most cases, these fractures are treated operatively with reamed intramedullary nailing, which is the standard of care.^3,11 However, certain patient factors, such as presence of a TKA with limited anterior bone stock, may make ORIF a preferred option. In this case we performed ORIF of a distal diaphyseal tibial fracture distal to a TKA using lag screw fixation with a medial non-locking neutralization plate.

Non-operative, closed management of diaphyseal tibia fractures may be indicated if casting and bracing are able to maintain strict alignment parameters of length, coronal and sagittal plane alignment, and rotation. Previously cited acceptable parameters are varus/valgus angulation <5°, procurvatum/recurvatum <5–10°, rotation 0–10°, and shortening <10–12mm.⁹ Alignment is initially maintained via a long-leg plaster splint or fiberglass cast followed by a longer period in a short-leg patellar-tendon-bearing cast or functional brace.⁹ If alignment shifts outside the acceptable parameters at any time, conversion to operative treatment is indicated. Non-operative management via these methods can be onerous for both surgeons and patients and has been associated with increased rates of nonunion (17%) and malunion (32%) compared to surgical techniques.² For these reasons, most surgeons elect for operative management.¹¹

Both ORIF and intramedullary nailing can lead to successful results. Modern plating techniques using minimally-sized incisions, careful soft tissue handing, and low-profile, anatomically-contoured locking plates can reduce the risk of infection, wound complications, and periosteal stripping that may contribute to risk of nounion.¹² ORIF does require a period of splinting and non- or partial-weightbearing immediately postoperatively. Intramedullary nails are inserted through relatively small incisions and result in less soft tissue disruption. Immediate weightbearing-as-tolerated is typically allowed after intramedullary fixation unless there is fracture extension into the tibial plafond. Many studies have compared ORIF and intramedullary nailing for diaphyseal tibia fractures, including several randomized controlled trials (RCTs). Regarding fractures in the distal tibial diaphysis specifically, studies have generally shown higher rates of malalignment with intramedullary nails with similar rates of deep infection and nonunion.¹² Rates of malalignment of distal tibia fractures have been reported to be between 8–50% for intramedullary nailing versus 0–17% for ORIF.¹² Deep infection is relatively rare with either operation (0–8%).¹² Reported rates of nonunion are similar after intramedullary nailing and ORIF, between 3–25%, though some literature suggests slower healing with use of locking plates specifically.¹² A recent large RCT of 258 operatively treated distal tibia fractures found no difference in patient self-reported disability or quality of life between ORIF and intramedullary nailing at 12 months postoperatively, though patients who underwent intramedullary nailing reported lower disability at 3 months.¹³ A follow-up study at 5 years postoperatively similarly found no difference in patient reported outcomes and no difference in rates of reoperation.¹⁴ This long-term follow-up study also found that patients’ reported level of disability did not change after the first 12 months after either operation.¹⁴

Plates for ORIF can be placed on either the medial or lateral surfaces of the tibia. Medial plating is convenient as the subcutaneous tibia is easily accessed, while exposing the lateral tibia for plating requires lifting off the anterior compartment musculature. Though open lateral plating requires greater dissection and exposure, the more robust soft tissue envelope is also protective against wound complications and plate prominence that are more common with medial plating.¹⁵ If considering medial plating, the surgeon should carefully access the thickness of the medial skin and subcutaneous fat and should take into consideration host factors that may influence wound healing, including age, diabetes, obesity, and tobacco use.¹² Minimally-invasive, percutaneous plating techniques that minimize the size of incisions and soft tissue stripping have been described for both the medial and lateral tibia.

Intramedullary nail insertion is more complicated when there is a previously implanted TKA in the injured extremity. Historically, surgeons have opted for ORIF for treatment of diaphyseal tibial fractures distal to a TKA out of concern for displacing the tibial base plate or causing an iatrogenic tibial tubercle fracture. More recently techniques for inserting a nail in the presence of a TKA have been reported. In 2022, Shaath et al. reported successful nailing of 9 fractures with no incidence of nonunion, infection, or arthroplasty complications.¹⁰ In their series, the mean distance from the tibial tubercle cortical density to the keel of the TKA tibial component was 24.1 mm, with a minimum distance of 19.5 mm. They were able to insert nails up to 11 mm.¹⁰ Also in 2022, Stevens et al. reported successful nailing with a minimum of 14.8 mm between the implant and anterior cortex.¹⁶ While these series show that intramedullary nailing can be successful in the presence of a TKA, this is an advanced technique that requires a high level of skill with intramedullary nailing and comfort managing the potential intraoperative complications should they arise. Tips for performing intramedullary nailing below a TKA include using a 2.0-mm Kirschner wire to find the start point and sound the path of the nail, utilizing a posterior blocking screw distal to the TKA tibial component, maintaining anterior trajectory of the ball-tipped guidewire with a cannulated awl or Yankauer suction tip, and passing reamers and the nail slowly around the TKA baseplate.^10,16

In the case described in this video, there was felt to be insufficient space for safe passage of an intramedullary nail as the distance from the tibial tubercle cortical density to the TKA tibial component keel measured 16 mm. ORIF was thus performed. The fracture was reduced through an anteromedial incision and fixed with two 3.5-mm lag screws. A 3.5-mm LCP was then applied to the medial surface of the tibia. There was no displacement of the posterior malleolus fracture fragment, and no fixation was performed due to the small size of the fragment and the expectation that the patient would be non-weightbearing initially postoperatively. The operative time was 64 minutes and blood loss was 100 milliliters. 

The patient’s postoperative course was uncomplicated. She was initially placed into a plaster splint, which was transitioned to a controlled ankle motion (CAM) boot at 2 weeks postoperatively. Her weightbearing was advanced to 50% at 6 weeks postoperatively and then to full weightbearing as tolerated at 12 weeks. At her most recent follow-up a 5 months, she had minimal pain with full weightbearing and no limitation in ankle range of motion compared to the uninjured contralateral side, and her fracture was found to be fully healed radiographically.

• Anatomically-contoured distal tibial locking-compression plates
• Weber reduction clamps of various sizes
• Small fragment locking and non-locking screws