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

CHAPTER 1

My name is Ken Rodriguez. I'm the Chief of Orthopaedics at Beth Israel Deaconess Medical Center. I'm a trauma surgeon and I take care of a gamut of cases ranging from high-energy trauma to geriatrics mostly. We have a couple of cases scheduled for today that came in last night. My first case is a 59-year-old female patient who fell down and had a torsion injury to her limb sustaining a distal tibia closed fracture, and a very spiral, fairly simple extra particular pattern. The issue with her is that she has a total knee replacement immediately above the tibia shaft fracture. So she would not be a candidate for our typical management, which is an intramedullary nail. So we will have to actually plate a tibia, which is something very classic and an operation that we don't often do anymore. But it's a good basic principles type of operation.

CHAPTER 2

So the interesting part about this is that it's a tibial shaft, but it's a very, very distal tibial shaft, right? So you measured it in the CT scan to have like six millimeters from the actual joint. So as a tibial shaft fracture, it would be amenable to intramedullary nailing, which is the standard of care. But this is - we're not doing that for two reasons. First of all, the fracture is very distal, so you may not grab enough of the distal piece of the tibia to actually be able to secure the stability, but most importantly, this scar represents a total knee replacement. So, the angle, the entry position for the IM nail is gonna be very hard. Her tibia actually has a very little space. Occasionally, we have done intramedullary nails around tibial prosthetics, but it's usually when the prosthetic lies a little bit posterior and you have a safe spot to put the nail somewhat more anteriorly. The risk with that is that if you're putting your nail too anteriorly to avoid the knee, you can damage the tubercle. And if you get a tubercle fracture, that's like a big problem. Yes. Right? That's almost as worse problem than what we're trying to solve. So for her, we're gonna do a more traditional medial plating, you know, and there's two approaches to it. You can actually just open it up and take a look, clamp it, and put a screw across it, and then put a plate that's called a neutralization plate. Neutralization because it neutralizes the forces acting on the screw that you put initially across the fracture plane, which is what define what does your fracture. Sometimes, if you can reduce it beautifully, you could potentially do a percutaneous technique, which is a little bit safer on the skin. But the important thing here is to make sure you get the reduction done adequately. So once you start by bringing the C-arm on and mark the margins of the fracture, I will stabilize the... Internally rotate a little bit here, Andrew? Yep. Coming in, coming in, distal, please. Almost like an angle shot, a little bit more. A little bit more into the fracture, awesome. Okay, everyone protected with the lead? Okay, fire. Make a mark there across, that's your proximal aspect. Could you go all the way to the knee first and mark where the end of the prosthetic is? Picture there, please. We got way - a lot of safety area, right, okay. Make a mark there. The point is, if we're gonna put a plate, you have to span the fracture but not get so close to the prosthetic that it's gonna be a problem, both in terms of running into the prosthetic or creating a stress fracture. Picture there, please. Okay, go a bit more generously distal 'cause I think we measured it. Picture. Picture. Put your picture device again. Yeah. Picture. Yeah, make a mark there. And then the final thing is you mark the actual joint. So make a corner, the anterolateral corner. Picture. Okay, make a little mark right there. Okay, make a little line here. Awesome, okay, all right. You can step out with the C-arm for a second. So we know that's the proximal aspect of the fracture is there, so most of our reduction work is gonna be done here. Hold it there, okay. I'll take the marking pen. Just keep it neutral. Oh, okay. Yeah, okay. So what we usually do, I usually kind of find the joint, which we marked this time, right? You can feel right there, the little angle, right? So it's something like this. So if you're gonna slide a plate, the plate's gonna be somewhere over here. So I try to make my incision a little bit more anterior so that you're not putting a suture line on the plate. So if we're gonna open distally, I think we can probably start doing something like this as the distal incision - go a little bit more... A little bit more distal, so we can slide the plate up if we have to. Then we know this is the crest. The crest is here. So we know our reduction is gonna be here. So we're gonna probably open up here, right? To kind of get a reduction. And then slide the plate and potentially go in this direction here. So why don't, let's start by opening here, here to here. Go ahead, Andrew.

CHAPTER 3

All right, we're making our incision. Yeah, and I'll take a forceps and a self-retractor of some sort, like a Weitlaner or something. I'll borrow the Bovie from you, I'll take the other one. That's great, you can put that there. Just gimme a little bit of traction. What's the Bovie at, guys? 40/40. Great, thank you, so you can feel already that you're giving the fracture right there. Usually, you'll find that the tissue's a bit stripped, right, just because of the trauma, right? So I'm looking at this, right? Our fracture is oblique and extending distally. So, let's see if we can see it. There you go, right, you can sense it there. Let's just see if we can actually see anything. I think it's up here, right? And it's nicely covered by periosteum, which is great, right? If there's a chance that we can fix this without taking down the periosteum, that's actually a desirable thing. Because this was the upper end of the... Yeah, that's what's weird. But we may have just - feel this... When you move this, right? Yes. It's kind of hard to appreciate it. Can I have a freer, please? All right, let's take a look at the... It's not very obvious, is it? There it is, it's right here. Okay, so, this is the distal apex, right? So it's a bit more lateral than what you would think. That's fine, so we, that's great 'cause then we can open here, right? And move and elevate the lateral muscles a bit better. There you go, put your finger there and feel it over there, right? Yep. So let's move this here. We can start reducing it and it's gonna be a great area to put this in. Okay, so can we take a reduction clamp, please? Let me see what options we have. Do you have the medium reduction clamps? Thank you. And let's try this. I'll try another.

CHAPTER 4

So feel that, guys, right, feel that there. Oh, yeah. You can see. So we have mapped it to be somewhat like this, so we're gonna... You wanna give it a try and see if you can reduce it? Sure. Yeah. So put one clamp on the behind and see. So what I would do is I would actually use your left hand for this. Okay. And use your right hand to control your traction a little bit, right? And what we'll do is... So hook your... There's the fracture plane. It's really visible, see? See it there? Mm-hmm. So go a little bit behind it. Because it's over the spiral. Yeah, there you go, right? And now get in there on this side here, right? Yeah. Right, gonna get this out. Okay, and now pull on it, right? And kind of like you're a little bit... You're a little bit oblique. Try clamping there, see what happens. Posterior on the heel. Yeah, it's okay. Take your time. Not the place you wanna... Right, so we're trying to do this without really damaging the periosteum, right? I'm gonna traction on you, right, that looks pretty good. A little bit off still. So let me just adjust for you a little bit. Let's just... Let's just bring you up a touch like this, right? Yep, oh, now I see it. Oh, do you see it there, right, it's a bit more obvious, so give that a try now. There you go, right, wiggle it, wiggle it, wiggle it. Okay, start clamping. There you go, right, see how nice it looks, okay? And now while you hold it there, I'm gonna reinforce you. Nah, this one doesn't lock... Can I have a different one, guys? This one doesn't click shut. The reason why you can't leave the clamp is because it's in the way of the plate. So, otherwise, you know, well what we can do is we have a very nice alignment. I'm gonna reinforce it with this. And you guys see the nature of the fracture, right? Yeah. So we're gonna be able to put a couple of good, it's oblique like this, so why don't we aim for a couple of lag screws in this direction. Okay, but like this, right? Perpendicular to the fracture plane at this particular level. So let's just confirm with the X-ray that we are actually happy with the way this looks. Can we bring the machine? Don't use the hand to turn it. Use the proximal piece so you don't put any torque on your reduction. And because we made the incision a bit more proximal than our marks, we got fooled by the X-ray a little bit. We can use this to actually put the plate, yeah, at the instrument. Internally rotate. Come a bit more this way now. Oh, that's good, let's try there. Picture there, please. Okay, so it looks good in the top, but not so hot at the bottom, right? So let's just work on that a little bit. So that tells you a couple of things. A little short, you probably... Yeah, yeah. So let's just release this, right? Yep. And let me just pull that up, right? Okay, but before you do that, let me just look at the fracture here. Oh, I see, you're a little bit displaced anteriorly. So, ready, pull, internally rotate a little bit. Stand by, lemme put my finger there. Still a little off. Yeah, but it's starting to look a touch better. Let me see here. Internally rotate for me. Hold on. There you go, lift up there. Let go, let go, let me... Yeah, that feels better. Let me feel that. Okay, let's just secure that. Don't put the other one yet, hold it in gentle internal rotation. Let's take another look. Let's see how it looks now. So we are trying to do this without disrupting the periosteum. A little bit this way. Or you can peel the periosteum and take a look at the whole fracture and make that touch easy, but that beats the purpose. See, it looks better already, push in, there you go. Picture there, okay, that's acceptable. Okay, so let's do a lateral view just to make sure that it's okay. Always check your images orthogonally. I've been occasionally cheated by... The other way, please. Yeah, all the way down, there you go. Lock it there for a second for me, yeah, okay. So now, lower your machine, actually, shoot there. See where we're at, okay, internally rotate a lot more, but don't displace it. Yeah, that's it, yeah, careful with it. Picture there, okay. Could you go distally and lower your machine some more? Okay, picture there. All right, so we are very good. Okay, you can come out. Now the trick is let's put a couple of lag screws without commuting the fracture. Careful with this, yeah, and back out. All right. Okay. Irrigation a little bit. Let's just clean up the wound a touch.

CHAPTER 5

And we're gonna start with a 3.5 drill, please. Maybe in a little bit of extension, is there any way to get that bad, or? Nah, that's okay. Okay. Sometimes the hardest thing is to not be fooled by what you think is gonna be better. This is a very, very good reduction. Yeah. Yes. Okay, so before we get too carried away, let's just plan our screw. We're gonna put one up there and one down there. Okay, 3.5, drill whenever it's ready. Thank you so much. So, the principle of the lag screw, right, is you put a larger hole on the proximal cortex and then a smaller hole in the distal cortex. So when you pass the screw, it's catching only in the distal cortex and the headless screw works as a lagging technique. So, Dr. Rodriguez, do you drill the pilot hole and the proximal piece first, and then the hole hole, or go through both and then the proximal? No, I do this one, right, like this to get my direction in the most... Okay, can we switch that to a 2.5? And now I take the 2.5 guide and I kinda shove it in there, right? Right, and then it's coaxial, so that I know it's coaxial and I can just hit it. Okay, we'll take the depth gauge, please. And we're gonna put our first screw. Now, when you're doing this, you gotta be a little bit careful you're not messing with where you're gonna be putting your plate, right? So that looks like a 28. That strike me as a little bit short for an oblique screw. Let's take a quick X-ray. It looks like it's gonna be a 28, guys, and we'll do it by hand. Non-locking screws. everything should be non-locking for this case, hopefully. Picture there, please. Okay, that sounds appropriate, okay, back up a little bit. Right, so now this is the size of the other thread. So this just sinks in. There's not - right? And it only catches threads on the other side, right? And then, if you look at the fracture plane, if you're deferring a true lag effect, when you squeeze it, you occasionally see a little bit of blood coming out from it, right? So this is a very, very nice and solid screw. Okay, so that's one, right? Why don't we do another one like right here? So we'll take this, we'll take the same jig, please. 3.5 again? Yeah. 3.5, yeah. And this spiral type of pattern, do you need to put the lag screws in two different directions? The drill guide, please. Well, ideally you wanna put the screw at a point where it's perpendicular to the fracture plane at that point. Because we are doing it without really being able to see the whole fracture, you're kind of taking a bit of a guess, but you kinda know the fracture is like this. So I'm gonna guess this screw is gonna be a bit like this, right? And this is just a guesstimate of where it should be. Right? If you could switch that to a 2.5. And then you put this... Right? And that's how you assure coaxial alignment. So 2.5 distal hole, 3.5 proximal hole. And then we put our second screw in, and that's our repair. That's what we need to do. So now the plate is just protecting those two screws, right? That's why it's called a neutralization plate because it neutralizes the stresses on the screws. It's a depth gauge, it's a little bit worn out, but the depth gauge reads like a 26. Let's take a 26, please. So if we did this properly, then, you know, we can - we kind of screw that in there, right? So now it's coaxial. If we did this properly, we should be able to take that clamp, and the fracture should remain aligned, right? So I'm gonna clamp this down. I'm gonna reinforce this one at really - a little touch. Okay, let's take the clamp and, hopefully, it won't go boing and fall apart, but... Nice, okay, so now we put our finger and we feel a very nicely reduced fracture. And now very gently we're gonna rotate the leg and let's take a picture, confirm that the fracture looks good and then we're gonna put a plate across it. Picture there, please. Again. All right, so you can, actually, don't back out yet. Let's go to the plates now and let's kind of gauge where our plate - what size plate we're gonna need.

CHAPTER 6

So these have a... These don't have a laterality to them, right? They're all the same. So let's pick a generous one. Let's go with these two. Okay, so, internally rotate. And now we're gonna just do a shadow. Picture. Picture. Picture. Okay, come a little bit more distal. Picture there. Picture. Internally rotate more, please. A lot more, like don't be shy about it. Picture. There you go, right, so this plate, picture there. Picture. Could you make a mark on the distal, oh, we have it, it's right at the joint line, so it's perfect. So this will be a great plate. Go proximal, now see how proximal this plate goes. Picture. That's a bit overkill. So we can probably do the slightly shorter one, which is this one here, right? Probably better with her total knee also than... Yeah, yeah, exactly. So let me just template this one. Picture. Picture. Go distally. Picture there. This will more than suffice. Can I get the next shorter one? Picture. Picture. Yeah, this will be fine. Okay, you can step out for a second, thank you. So the next step is to slide the plate up, you know, and I guess we could slide it in this direction, right? Since we take advantage of the big gap we did, but we're gonna have to open it here anyway. So can I take a 15 blade and you can just open that just enough to slide the plate. So just that part there. Just from there to there. Come, come a little bit in this direction. Yeah, that's great. Excellent. Bovie and little forceps, please, Adsons. Great, great, that's more. So here. Dissecting scissors, please. The one thing I always end up doing is lacerating the saphenous vein. But welcome to, right, so we just, again, always supraperiosteum, right? So there's that here, buzz that for me. Buzz again. Thank you. Ah, of course, I missed it, buzz it. Okay, freer, please. Scissors back. It's all right. So we make a little bit of room, right? And then slide the plate up, please, and grab it there. Awesome. All right, can I take the Kocher again? Need a little bend in our plate. No, I have it. I have it here. Yeah, the Kocher is great. Here, I'll grab it here. There you go. Right. Okay, so now we have to find the perfect position for the plate. And it's a little bit more anteromedial than what you would think. Come in with the C-arm, please. And internally rotate right there. Picture there. Okay, a little bit more distal. Picture there. Okay, so it's two prox. Let's just go more that way, that makes more sense. Picture. Uh, too much. Picture there. Internally rotate some more, like a lot more. Picture. Can you center your machine so the ankle looks, yeah, picture there. Feels a little bit disappointing in the way it's fitting. Let's go out a little bit with this. And let's move it a bit more anterior. See if we can go a little bit more anterior. Picture there. Back up, I need to play with this a touch. It usually fits really nicely. Internally rotate more for me. Thank you. Hmm. Internally rotate. All right, let's just take a guess. What would happen if we put it... Here? Can you come in with this C-arm for one more - lemme stand on this side 'cause I'm going to press it in like this. All right, picture there. Okay, that's what we're gonna do, right? So it's gonna mold. It's gonna mold up in a minute. Yeah. Okay, back up. Yeah. So let's take then a 2.5 drill, guys. We're gonna just do one screw here. Power again? Power is good for this one. This is not a lag one, so I don't care so much. And that's a bit long. So let's take a 26. Yeah. So, you put your finger there and make sure that plate's not too posterior, too anterior. 26. Thank you. Pull that out, guys. Okay, handheld screwdriver. Thank you, so now we're gonna... We are looking at this and feeling, making sure it's not inappropriately prominent in any particular spot. Okay, let's take a picture now, see how it looks, and now you would - super, there you go, you kind of get it in the perfect lateral contour. Okay, let's get a picture. Okay, nice. Go a little bit more distal. Picture, okay. Back away. So I'm looking at this and I'm trying to decide if it's worth moving it proximally one hole. Can I have the freer, please? Let me just feel here. It's not gonna be prominent, it's gonna be okay. And we are missing that hole. And we got a little bit of prominence from that screw head over there. See how it's overlaying the plate? Yeah. So let's just go with this. Let's take another drill, please. This one? Yeah. We're gonna try to secure that distal part here. Can you guys gimme a little retraction there? A little rectangular right-angle retractor. Yeah, just on the skin, so I can get one screw in there so I can anchor it distally so we know that we're above the joint 'cause that's our mark. And we're gonna go a little perpendicular to the plate. This is back to you, I'll take the depth gauge. Pull a bit harder on that side. Thank you. Okay, let's go, ooh, that's a generous one. That sounds right, let's go with a four. Let's go with a 38, in power. So, for this plate, we need like three and three. The plate prevents too much torque going to the original two screws. Thank you. Handheld. A little bit of retraction there. Okay, that makes me happy there, it's not very proud. Let's go up here. How far are we heading, so we got like... So if we do one, two... Why don't you skip two, put one here. Let's see how far the plate goes. Yeah, actually do this one. Why don't you guys... And just drill it straight in. Yeah, yeah, yeah. Depth gauge, please. And you're gonna put a screw in power in a minute. It's a skinny bone. Measures at... Just start with a 22, please. 22. Yeah. Don't slam it down all the way just by... All right, handheld screwdriver, please. And then we're gonna get the 2.5 drill back one more time. Don't kill it, just a finger plus. Yeah, a finger plus is enough. Just enough to put the plate down, right? 2.5 drill, please. And then we'll do one more. Let's see if we can, can you go - here, lemme just get you a little bit more... Okay, get that last one there. Nice and perpendicular. Go ahead. Measure that. Try to do it down, right, with one hand and then it hooks and then you bring down, so it's really a 26, 28 - 24, please. So whenever it doesn't go in right away, it's because you're not in the right angle. So go ahead. Go ahead. Okay. Okay, that's three there, let's get a couple here. If you'll excuse me, I'm gonna - let me see. So we got this. This is great. Let me feel how, maybe we can get this one. Can you come in with the C - with the X-ray machine for a little bit? Hold in internal rotation. Yeah, picture there. That's very nice. So let's do one distal to that and one proximal and that should be it. Okay, can you go all the way proximal to see how far proximal we are with the screws and the plate? Picture there. All right, that's great, okay, you can back out now. Thank you. We'll take the drill, please. 2.5 drill. Yeah. And we know this is, we're getting a little bit close to the ankle, so we're gonna just aim it a little bit more up now. Let's go with a 42, please. And we're gonna get it through here, I think Through here? Yeah, let's just see if we can do it. So we have one. One, two, right? Yeah, let me just extend it. Can I take a 15 blade? There's no... Actually, no, let me see, hold on. So, one. Do we have a second one there already? Over there. Oh, I see. Okay, so this is easy. Drill. I will take it without the guide. Without the guide. Let's go with a 36. Can you put it like this? Come in with the machine, please. Picture there. Picture. Let's go with a 34. Yep. 34. Thank you. To make sure that we have enough size there to put the screw head. 15 blade. Okay. All right. That's it, let's give it a little irrigation. Let's get a couple of final pictures in AP and lateral. And let's see how it looks. Here's these instruments back to you. Now that it's fixed, we can move it from both sides. Picture there. Center a bit more. Picture there. Nice, save that, go a bit more distal. Picture. Save that, internally rotate for me. Picture there, thank you. Save that, okay, let's go to a full lateral. A little bit more. Watch your fingers, I'm gonna press down for you. It's not all the way. Ready? Thank you. Okay, picture there. Get a bit more internal rotation. Lower your machine a touch. Picture. A bit... Picture. Go distally. Picture,. Distally. Yeah, picture there. So let me just get a good lateral. Picture. Save that. Come proximally. Picture. All right, thank you so much, you're all set.

CHAPTER 7

So we'll do just a nice closure and we can do some nylons or Prolenes and stuff. And... What's all that? Just Bovie. Can I have a sponge, please? I think it's nice and - yeah. All right, let's get some sutures. Let's run a 2-0 Monocryl, and then we'll do 2-0 nylons on the surface. Yep. For this one? For this one I'll just put one 2-0 there and then a couple of nylons. So when we splint her, make sure she gets a little pocket there, right? You guys have any questions? Pretty straightforward. And an alternative, we don't do very often tibial shaft plating. It's either IM nailing, or it's part of a pilon or something that you end up plating. How many lags? How do you decide how many lag screws you need? Oh, I just kinda estimate it just to make sure we span the fractures somewhat okay. And we are gonna be very protective of her. So a couple of lag screws and plate with three screws done above and three below. So just get a very deep one and then go straight to nylons. I would just do something straightforward like this. Just catch it. Oh, just a big one, got it. Just a big one, right? Okay. You got it. Like this. Mm-hmm. And then close it there, and then go to 2-0 nylons, and then do interrupted 2-0 nylons. So that's that, the next - a little deeper. A little deeper, right? That's gonna leave a knot, very superficial. So look at this one, how deep this one goes, right? So what you wanna do is you wanna just - don't be shy. Just grab it deep. Just like something like this, right? This is just to get a little bit of tissue over the plate. Notice how we put the incision anteriorly, right? Yeah. So you don't have to be suturing over a plate. And now you can go straight to the 2-0 nylons. You want simple? Yeah, cut them both. And now put 2-0 nylons there. You can do inverted mattresses, so that the skin's a little bit nice. Not too tight. Okay. All right, this is usually when I scrub out.

CHAPTER 8

So, we completed the case. It was an uneventful case. It went very well. We decided to perform a reduction of the oblique fracture with traction manipulation and application of reduction clamp. We then applied two lag screws in a standard manner, and then applied a medial neutralization non-locking plate with about two or three screws proximally, and two or three screws distally just to protect the lag screws. We were able to slide the plate from distal to proximal and secure it with a good anatomic alignment and without compromising the proximal knee replacement in any way.