Tibia and fibula, proximal: intraarticular bicondylar fracture with a nonimpacted, metaphyseal component—41-C3 with diaphyseal involvement

10.1055/b-0034-87652

Tibia and fibula, proximal: intraarticular bicondylar fracture with a nonimpacted, metaphyseal component—41-C3 with diaphyseal involvement

Jong-Keon Oh

Case description

A 38-year-old man injured both legs in a car accident sustaining a closed intraarticular fracture of the proximal tibia with extension to the diaphysis. There was a 44-C ankle fracture and multiple metatarsal fractures on the ipsilateral foot. The patient also had a segmental tibial fracture and a calcaneal fracture on his other leg. The neurovascular status was normal. Several small open wounds were noted mainly on the anterior aspect of the proximal tibia. The level of contamination was minimal and there was no soft-tissue defect that needed to be covered with a flap. Initial management consisted of debridement and the application of a bridging external fixator. It took 2.5 weeks for the soft tissue to settle down. This was verified by the presence of a wrinkle sign.

a–b Preoperative x-rays show a multifragmentary fracture of the proximal tibia involving both condyles and extending into the diaphysis. A coronal split of the medial condyle can be seen. c–f Three-dimensional CT scans show the extent and location of the articular fragments. Note that the posteromedial articular fragment is connected to the posterior part of the lateral articular fragment. Also note the significant comminution of the metaphysis just below the medial condyle.

Indication for MIPO

Operative treatment was mandatory to restore the articular congruency and the overall alignment of the leg. Intramedullary nailing was not possible due to the fracture morphology. Possible treatment options would be ring-type external fixation, conventional open reduction and internal fixation with dual plating, or MIPO.

The use of a ring external fixator has been reported to achieve similar functional results to dual plating [ 1]. But these studies ignore the patients’ morbidity and significant discomfort throughout the whole course of treatment when a ring fixator is used. The only theoretical benefit of using ring external fixator is that this form of treatment gives less chance of soft-tissue breakdown when compared to plating.

However, with the careful application of biological plating concepts and techniques the rate of wound complications is significantly reduced when compared to dual plating with a midline incision. A recent study supports this, reporting much higher articular malunion in the hybrid external fixation group (40%) compared to the lateral locked plating group (7%) and higher overall complications in the external fixation group (48% versus 27%) [ 2].

In this case, the significant comminution of the metaphysis of the medial column strongly influences the choice of treatment. Open reduction and internal fixation would carry a high risk of devitalizing the fragments to achieve correct reduction. Therefore a MIPO strategy has many advantages and the technique is demonstrated in this example.

Preoperative planning

Bridging external fixation

Because this was an open fracture, debridement of the wound and bridging external fixation was planned as the initial management. At the time of bridging external fixation the placement of the pins was carried out so as not to obstruct the area of definitive fixation ( Fig 19.3-3a ).

Articular reconstruction

From analysis of CT images, a 10 cm medial longitudinal incision is planned centered over the fracture line between the tibial tuberosity anteriorly and posteromedial corner of the proximal tibia posteriorly. This incision minimizes soft-tissue stripping (see Fig 19.3-2 and Fig 19.3-5 ). The coronal split is then reduced using pointed reduction forceps, and a lag screw in an AP direction is then inserted to hold the reduction. Next, the interval between anteromedial and anterolateral fragments will be opened to reduce the articular depression on the lateral condyle. Reduction between the anterolateral and the posterolateral fragment is achieved through this exposure. Once the reduction has been obtained, multiple subchondral screws are placed from lateral to medial to fix the articular fragments ( Fig 19.3-3b ).

Metadiaphyseal reduction

Reduction of the different fragments is achieved by pulling the fragments against the plate using reduction screws. Restoring length is not needed because the length was well restored with the initial bridging external fixator ( Fig 19.3-3b ).

Planning for the articular reconstruction. The arrow indicates the site of incision needed to achieve the reduction between anteromedial and posteromedial fragments.

a–b a Postoperative x-ray taken after bridging external fixation shows restoration of length and alignment. b Preoperative planning shows the sequence of reduction screw placement after reconstruction of the articular surface. K-wires will be used to provisionally maintain the correct position of the plate distally. Cortex screws number 2 and 3 are inserted for indirect reduction. Additional screws number 4 and 5 are inserted to fix the fracture. The most distal K-wire is replaced with an LHS (screw number 6).

Operating room setup

Anesthesia

General anesthesia is advisable as the expected operation time is more than 3 hours. A Foley catheter is inserted. A sterilized tourniquet is prepared as an option.

Patient and image intensifier positioning

The patient is positioned supine on the radiolucent operating table with knee in 30° flexion. A roll is placed under the buttock. An alternate position would be to place uninjured leg on a leg holder with the hip and knee flexed around 90°. The C-arm monitor is set up at the side of contralateral shoulder. The image intensifier is placed on the side of the uninjured leg ( Fig 19.3-4 ).

Only gold members can continue reading. Log In or Register to continue