Guidelines in Fracture Management - Proximal Tibia by Babhulkar
26 Proximal & Distal Tibia Fractures Plate Or Nail · • Deforming Forces ... • Understand...
Transcript of 26 Proximal & Distal Tibia Fractures Plate Or Nail · • Deforming Forces ... • Understand...
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Proximal Tibia Fractures
MIPPO Plate Or Intra‐Medullary Nail ?
Donald Wiss MD Cedars‐Sinai Medical Center Los Angeles, California
Proximal Tibia Fractures Plate Versus NailIs There A Difference In Outcomes?
• Knee Pain
• Rates Of Union
• Mal-Union
• Mal-Reduction
• Infection
• Implant Removal
Lindvall EL, Sanders R, DiPasquales T, et. al: Intra-Medullary Nailing
Versus Percutaneous Locked Plating Of Extra-Articular
Proximal Tibia Fractures: Comparison of 56 Cases
J Orthop Trauma 23: 485-492, 2009
N=22 Nails N=34 Plates
Outcome Measures: Union Rates, Malunion, Malreduction,
Infection, & Implant Removal
No Distinct Advantage With Either Method Of Treatment
No Statistically Significant Differences in Outcome Measures
Apex Anterior Mal-Reduction Most Common Deformity In Both Groups
Implant Removal More Common In The Plate Group
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Proximal Tibia Fractures
MIPPO / Concept / Theory
• Minimize Surgical Footprint
And The Subsequent
Biological Impact
• Promote Healing
• Decrease Infection
• Improve Outcomes
Proximal Tibia Fractures
MIPPO / Concept / Theory
• Advances In Past 20 Years
• Minimally Invasive Techniques
• Peri-Articular Locked Plates
• Adjunctive Reduction Tools
• Better Intra-Operative Imaging
• Early Rehabilitation Protocols
MIPPO Proximal Tibia
Principals
• Articular Segment
• Open Reduction
• Anatomic Articular Surface
• Rigid Fixation Absolute Stability
• Meta‐Diaphyseal Segment
• Fracture Not Exposed
• Controlled Distraction
• Indirect Reduction Relative Stability
• Adjunctive Reduction Tools
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Proximal Tibia Fractures
4 Strong Indications For MIPPO Plating
• Severe Soft Tissue Injury
• Complex Fracture Patterns
• Intra‐Articular Fractures
• Complex Extra‐Articular Fxs
• Peri‐Prosthetic Fractures
• Fractures Not Amenable To Nailing
Proximal Tibia Fractures
Indication For MIPPO Plating
• Severe Soft Tissue Injury
• Complex Fracture Patterns
• Intra‐Articular Fractures
• Complex Extra‐Articular Fxs
• Peri‐Prosthetic Fractures
• Fractures Not Amenable To Nailing
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Proximal Tibia Fractures
Indication For MIPPO Plating
• Severe Soft Tissue Injury
• Complex Fracture Patterns
• Peri‐Articular Fractures
• Complex Extra‐Articular Fxs
• Peri‐Prosthetic Fractures
• Fractures Not Amenable To Nailing
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Proximal Tibia Fractures
Indications For MIPPO Plating
• Severe Soft Tissue Injury
• Complex Fracture Patterns
• Peri‐Articular Fractures
• Complex Extra‐Articular Fxs
• Peri‐Prosthetic Fractures
• Fractures Not Amenable To Nailing
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Proximal Tibia Fractures
Indication For MIPPO Plating
• Severe Soft Tissue Injury
• Complex Fracture Patterns
• Peri‐Articular Fractures
• Complex Extra‐Articular Fxs
• Peri‐Prosthetic Fractures
• Fractures Not Amenable To Nailing
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Proximal Tibia Fractures
MIPPO Requirements
• Works Best On Acute Fractures
• Reducible Fracture
• Understand Anatomy
• Deforming Forces
• Safe Zones / Implant Placement
• High Quality Imaging
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Proximal Tibia Fractures
Pre-Op Planning
• Patient Positioning
• Create A Stable Platform
• Bone Foam Or Blanket Pack
• Unobstructed Lateral Imaging
• Move The C-Arm NOT Limb
Proximal Tibia Fractures Pre-Op Planning
• Surgical Drawing Helpful
• Equipment
• Peri-Articular Locking Plates
• Reduction Tools
• Ext Fix Or Femoral Distractor
• Peri-Articular Clamps
• Joysticks
Proximal Tibia Fractures Operative Sequence
• Articular Reduction
• Controlled Distraction
• Restore Alignment
• Technical Tricks
• Understand Deforming Forces
• Submuscular Plating
• Span Zone Of Comminution
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Proximal Tibia Fractures
Operative Sequence
• Articular Reduction
• Indirect Reduction If Non-Displaced
• Direct Reduction When Displaced
• Exposure As Necessary
Proximal Tibia Fractures Operative Sequence
• Controlled Distraction
• Traction
• Femoral Distractor
• External Fixation
Proximal Tibia Fractures Operative Sequence
• Restore Limb Alignment
• Length
• Alignment
• Rotation
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• Reduction Tools
• Distractor Or Ex Fix
• Strategic Bump
• Schantz Pins / Joystick
• Articulated Device
• Peri-Articular Plate
Proximal Tibia Fractures Operative Sequence
Proximal Tibia Fractures
Operative Sequence
• Understand Deforming Forces
• Hip & Proximal Femur
• Distal Femur
• Proximal Tibia
• Distal Tibia
Proximal Tibia Fractures
Operative Sequence
• Submuscular Plating
• Know Your Anatomy
• Learn Safe Corridors
• Confirm With C-Arm
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Proximal Tibia Fractures
Operative Sequence
• Span Zones Of Comminution
• Long Plates
• Spaced Screws
• Balanced Fixation
• Stable Construct
Proximal Tibia Fractures
Operative Sequence
• Technique
• Controlled Distraction
• Anatomic Specific Plates
• Reduction Tools
• Skilled Assistant
• High Quality Imaging
MIPPO Proximal Tibia
Concept Rather Than Technique
• Substantial Learning Curve
• Start With Less Complex Fractures
• Reduction Most Important Goal
• Size Of Incisions Less Critical
• Not A Faster Surgical Procedure
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MIPPO Proximal Tibia
38 Year Male S/P Pedestrian Versus Motor Vehicle
Operative Sequence For MIPO Proximal Tibia
Proximal Fragment Fixation
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Non‐Locking Screw Distally To Bring Plate To Bone Followed By Lag Screw
Final Fixation Construct
42 Yr Male S/P 100 Kilogram Crate Fell Onto Leg At Work
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Articular Extension: Nail Or Plate ?
Percutaneous Submuscular Plating. Mild Residual Deformity
2 Year Follow‐Up Healed And Working
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28 Yr Male Fell After Snowboard Jump
Raft Plating Tibial Plateau & Submuscular Plating Of Shaft
33 Yr Male S/P Motor Bike Accident With Grade 1 Open P/3 Tibia
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I & D With Submuscular Plating Early Healing At 3 Months
Proximal Tibia Fractures
Intra‐Medullary Nailing
• Advantages Of Nailing
• Load Sharing Implant
• Load Sharing Implant
• Load Sharing Implant
• Soft Tissue Friendly
Intra‐Medullary Nailing
Problems & Challenges
• Classic Infra‐Patellar Nailing With
The Knee Flexed Leads To
Predictable Deformities
• Flexion (Apex Anterior)
• Post Translation Distal Fragment
• Valgus
• 2o Pull Of Extensor Mechanism
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Proximal Tibial Fractures
Challenges With Nailing
• Short Segment
• Wide Or No Medullary Canal
• Thin Metaphyseal Cortex
• Muscle / Deformity Factors
• Nail Cannot Reduce Fracture!
Intra‐Medullary Nailing
Techniques To Overcome Deformity
• Supra‐Patellar Nailing
• Correct Starting Point
• Implant With Very Proximal Bend
• Reduction Devices & Tools
• Percutaneous Clamps
• Uni‐Cortical Plate
• Blocking Screws
• Distractor Or External Fixator
• High Quality Imaging
Intra‐Medullary Nailing
Techniques To Overcome Deformity
• Supra‐Patellar Nailing
• Correct Starting Point
• Implant With Very Proximal Bend
• Reduction Devices & Tools
• Percutaneous Clamps
• Uni‐Cortical Plate
• Blocking Screws
• Distractor Or External Fixator
• High Quality Imaging
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Intra‐Medullary Nailing
Techniques To Overcome Deformity
• Supra‐Patellar Nailing
• Correct Starting Point
• Implant With Very Proximal Bend
• Reduction Devices & Tools
• Percutaneous Clamps
• Uni‐Cortical Plate
• Blocking Screws
• Distractor Or External Fixator
• High Quality Imaging
Intra‐Medullary Nailing
Techniques To Overcome Deformity
• Supra‐Patellar Nailing
• Correct Starting Point
• Implant With Very Proximal Bend
• Reduction Devices & Tools
• Percutaneous Clamps
• Uni‐Cortical Plate
• Blocking Screws
• Distractor Or External Fixator
• High Quality Imaging
Intra‐Medullary Nailing
Techniques To Overcome Deformity
• Supra‐Patellar Nailing
• Correct Starting Point
• Implant With Very Proximal Bend
• Reduction Devices & Tools
• Percutaneous Clamps
• Uni‐Cortical Plate
• Blocking Screws
• Distractor Or External Fixator
• High Quality Imaging
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Intra‐Medullary Nailing
Techniques To Overcome Deformity
• Supra‐Patellar Nailing
• Correct Starting Point
• Implant With Very Proximal Bend
• Reduction Devices & Tools
• Percutaneous Clamps
• Uni‐Cortical Plate
• Blocking Screws
• Distractor Or External Fixator
• High Quality Imaging
Intra‐Medullary Nailing
Techniques To Overcome Deformity
• Supra‐Patellar Nailing
• Correct Starting Point
• Implant With Very Proximal Bend
• Reduction Devices & Tools
• Percutaneous Clamps
• Uni‐Cortical Plate
• Blocking Screws
• Distractor Or External Fixator
• High Quality Imaging
Intra‐Medullary Nailing
Techniques To Overcome Deformity
• Supra‐Patellar Nailing
• Correct Starting Point
• Implant With Very Proximal Bend
• Reduction Devices & Tools
• Percutaneous Clamps
• Uni‐Cortical Plate
• Blocking Screws
• Distractor Or External Fixator
• High Quality Imaging
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Intra‐Medullary Nailing
Techniques To Overcome Deformity
• Supra‐Patellar Nailing
• Correct Starting Point
• Implant With Very Proximal Bend
• Reduction Devices & Tools
• Percutaneous Clamps
• Uni‐Cortical Plate
• Blocking Screws
• Distractor Or External Fixator
• High Quality Imaging
Intra‐Medullary Nailing
Key Technical Issues
• Reduction Before Nailing
• Ream With Fracture Reduced
• Maintain Reduction Thru Case
• Lock Proximal & Distal
• Not Always Easy
Clinical Cases
Intra‐Medullary Nailing
Proximal Tibia Fractures
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59 Yr Male Struck By Car Sustaining An Open Multifragmentary Segmental Fracture Of The Tibia
Uni‐Cortical Plate & Locked Nail 18 Year Follow‐Up
Segmental Tibia Fracture After A Motorcycle Accident
Reduction With A Percutaneous Clamp
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Post‐Op Nailing 8 Month Follow‐Up
46 Yr Male S/P Peds vs Auto Accident Sustaining Multiple Injuries
Percutaneous Assisted Reduction; Closed Locked Nailing
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Displaced Proximal Third Tibia Fracture
Intra‐Medullary Nailing Via A Supra‐Patellar Approach
Displaced Proximal Third Tibia Fracture; Supra‐Patellar Nailing
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Operative Sequence, Distal Screw Insertion, Black‐Slap, Compress
Final Fixation With A Locked Intra‐Medullary Nail
Proximal Tibial Fractures
Preventable Problems With Nailing
• Mal‐Alignment
• Mal‐Rotation
• Mal‐Union
• Fixation Failure
• Non‐Union
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Proximal Tibia Fractures
Problems With Nailing
• IM Nailing Of Proximal Tibia
Fractures Is Technically Difficult &
Often Results In Mal‐Alignment
• Surgeons Without Experience
Nailing These Fractures Shoulder
Consider Other Fixation
Techniques
Thank-You