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

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tips and tricks for proximal and distal tibia fractures
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Tips And Tricks for Proximal and Distal Tibia Fractures in 5 - - PowerPoint PPT Presentation

Nov 18, 2023 393 likes •956 views

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

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Tips And Tricks for Proximal and Distal Tibia Fractures in 5 Minutes!

Bob Zura MD LSU Health New Orleans OSET 2017 Las Vegas

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Disclosures

  • Consultant:

– Smith-Nephew – Bioventus – Cardinal Health

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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

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The Solution

  • Nails are just plain Better – here is how to

do them in the tibia.

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The Perfect Starting Point

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You Don’t Valgus….

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  • Proximal fragment

extended

– Pull of extensor mechanism

  • Posterior directed

nail insertion angle

  • Lack of posterior

cortex

You Don’t want:Apex Anterior Angulation

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Apex Anterior Angulation

  • Proximal fragment

extended

– Pull of extensor mechanism

  • Posterior directed nail

insertion angle

  • Lack of posterior cortex
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Starting Point

  • Ideally

–Lateral to use lateral cortex –Parallel to Anterior cortex

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Blocking Screws

  • Blocking screw(s)

are placed into

DISTAL portion of

proximal fragment through percutaneous wounds

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  • Posterior to the central

axis so nail passes anterior to the blocking screw

Posterior Blocking Screws Control Apex Anterior Angulation

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  • Lateral to central

axis so nail passes medial to the blocking screw

Lateral Blocking Screws Control Valgus Angulation

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Dunbar et al., JOT 2005

Provisional Plating

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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
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Case

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Case

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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
  • f 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

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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

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Distal 1/3 Tibia Fractures

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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

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Case: intra-articular extension

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Case

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Case

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Case

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Provisional Plates

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Case

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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
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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

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Case

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Case

  • ORIF of fibula prior to

nail

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Case

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Case

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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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THANK YOU