Tips And Tricks for Proximal and Distal Tibia Fractures in 5 - PowerPoint PPT Presentation

Tips And Tricks for Proximal and Distal Tibia Fractures in 5 Minutes! Bob Zura MD LSU Health New Orleans OSET 2017 Las Vegas

Disclosures • Consultant: – Smith-Nephew – Bioventus – Cardinal Health

The Challenge • Deformity at Both ends of the Bone but more of a proximal issue – Valgus and Extension • Terrible Soft Tissue Environment • Desire Early WB and Healing – Healing more of a distal issue

The Solution • Nails are just plain Better – here is how to do them in the tibia.

The Perfect Starting Point

You Don’t Valgus….

You Don’t want:Apex Anterior Angulation • Proximal fragment extended – Pull of extensor mechanism • Posterior directed nail insertion angle • Lack of posterior cortex

Apex Anterior Angulation • Proximal fragment extended – Pull of extensor mechanism • Posterior directed nail insertion angle • Lack of posterior cortex

Starting Point • Ideally –Lateral to use lateral cortex –Parallel to Anterior cortex

Blocking Screws • Blocking screw(s) are placed into DISTAL portion of proximal fragment through percutaneous wounds

Posterior Blocking Screws Control Apex Anterior Angulation • Posterior to the central axis so nail passes anterior to the blocking screw

Lateral Blocking Screws Control Valgus Angulation • Lateral to central axis so nail passes medial to the blocking screw

Provisional Plating Dunbar et al., JOT 2005

Provisional Plating • Placed through traumatic wounds • Applied in areas that are stripped to avoid additional injury to extraosseous blood supply • 3.5 mm LCDCP • 3.5 mm Unicortical screws (10-12mm length) • All removed after nailing Dunbar et al., JOT 2005

Case

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Semi-Extended Nailing Tornetta CORR 328, 1996 • Allows better angle for starting point and eliminates some pull of extensor mechanism • Showed a complete reduction in extension of the proximal fragment in 25 consecutive patients • Nailed in 15 degrees of flexion and a 2/3 medial parapatellar arthrotomy that allowed lateral patellar subluxation and use of the trochlear groove to nail

Suprapatellar Nailing • Suprapatellar Versus Infrapatellar Tibial Nail Insertion: A Prospective Randomized Control Pilot Study. Chan DS1, Serrano-Riera R, Griffing R, Steverson B, Infante A, Watson D, Sagi HC, Sanders RW. • Overall, there seemed to be no significant differences in pain, disability, or knee range of motion between these 2 tibial intramedullary nail insertion techniques after 12 months of follow-up

Distal 1/3 Tibia Fractures

Distal Tibial fractures with limited articular involvement Nork et al. Intramedullary nailing of distal metaphyseal • tibial fractures. JBJS 2005. • 36 fx’s within 5cm of joint. 10 with articular extension. • 92% <5deg • No loss of reduction • 1 infx, 1 iatrogenic fx • 23.5 week healing • Limited function but improvement with time • Konrath and Rzesacz concur

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Case: intra-articular extension

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Provisional Plates

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Fibular fixation? • Strauss (Egol) et al. The effect of concurrent fibular fixation on the fixation of distal tibia fractures: a lab comparison of IM nails with locked plates. JOT 2007. • 8 paired cadaveric tibiae • 1 IM nail 1 locked plate – Tested and then fibular osteotomy • An intact fibula improved fracture fixation

Fibular fixation? • Egol et al. Does fibular plating improve alignment after IM nailing of distal metaphyseal tibia fractures? JOT 2006 • Fibular fixation associated with maintenance of reduction beyond 12 weeks

Case

Case • ORIF of fibula prior to nail

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Poller Screws • Krettek et al. The use of Poller screws as blocking screws in stabilizing tibial fractures treated with small diameter nails. JBJS Br 1999 • 21 tibia fractures – 10 PROX 1/3, 11 DISTAL 1/3 – 18.5 MONTHS • All healed 5.4 +/- 2.1 months • Varus -5 to 3, sag -6 to 11

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