The patient is placed in the supine position on a regular operating-room table. A tourniquet is not required for the procedure but may be used if desired. Use of either general or spinal anesthesia is satisfactory. The entire leg is prepped from the toes to the groin. Prophylactic intravenous antibiotics, usually a single preoperative dose of cephalosporin, is
recommended. The location and length of the incision is drawn on the skin before application of an adhesive iodine-impregnated drape (Fig. 28.4
). I prefer to carry out the procedure in the seated position at the foot of the table with the surgical assistant also seated.
A long anterior incision is placed 1 cm lateral to the tibial crest and corresponding to Langer’s lines (Fig. 28.5
) (1). The incision is curved gently at its distal portion at the level of the metaphyseal flare in the supramalleolar region. A long surgical incision is preferred because it allows satisfactory exposure of the tibia and allows the surgeon to avoid unnecessary, vigorous, skin retraction, particularly on the medial skin flap (Fig. 28.6A
) (6). The saphenous vein or nerves need not be sacrificed in the distal portion of the incision because the plate may be placed beneath these structures, leaving them completely intact (see Fig. 28.6B
). They should be dissected only enough to allow passage
of the plate beneath them. In addition, the sheath of the tibialis anterior tendon need not be entered.
Figure 28.3. The condition of the skin is ascertained before undertaking ORIF. In this case, no ecchymosis or fracture blisters are found. A minimal amount of edema is present and a fine wrinkle pattern can be noted on the skin 10 days after the initial injury.
Figure 28.4. Planned surgical incision is indicated on the skin with a marker to assist in the surgical approach as well as wound closure. The operative area is draped with adhesive iodine.
Figure 28.5. The surgical incision is anterior and curvilinear. It begins 1 cm lateral to the tibial crest and curves medially in the distal portion.
Figure 28.6. A. The surgical incision is carried through the skin and subcutaneous tissue. B. The small dental instrument indicates the location of the distal saphenous structures, which are preserved during the surgical approach and the procedure. C. The small dental instrument indicates the presence of fracture hematoma, which is removed for exposure of the fracture.
The skin and subcutaneous flap are raised in a medial direction just enough to allow exposure of the posteromedial border of the tibia and the butterfly fragment, which are seen after removal of the fracture hematoma. The dissection remains extraperiosteal. The periosteum is frequently noted to be stripped at the fracture edges as a result of fracture displacement. If any additional periosteal elevation is necessary to evaluate reduction, then not more than 1 or 2 mm at the immediate fracture edge should be elevated. The remainder of the procedure should be carried out entirely extraperiosteally (Fig. 28.7
Figure 28.7. After evacuation of the fracture hematoma, the fracture, including the minimally displaced posteromedial butterfly, can be seen. The edges of the fracture are compared to the surrounding hemorrhagic periosteum and are noted to be white. This indicates the amount of periosteum that was stripped by the injury itself. The stripping done by the injury allows for sufficient visualization of the fracture edges and subsequent reduction. No further periosteal stripping should be necessary for reduction and fixation of this fracture. The periosteum is hemorrhagic because of the injury and also because no tourniquet is used.
Figure 28.8. The posteromedial butterfly is directly reduced with bone forceps. Even though the butterfly is directly reduced, the bone forceps is applied extraperiosteally; no soft-tissue stripping is necessary to accomplish the reduction. The small elevator indicates the location of the posteromedial butterfly fragment.
Once the surgical approach has been completed and satisfactory exposure of the fracture site and the medial surface of the tibia has been achieved, then the preoperative plan is followed in order for reduction and fixation of the fracture (see Fig. 28.2
The ankle-joint axis is initially marked with a reference Kirschner (K) wire placed by hand in the soft tissues at the level of the ankle joint (step1, Fig. 28.2B
). The butterfly fragment in the nondisplaced fracture lines are reduced and secured with bone forceps placed without stripping additional periosteum. If significant displacement of the butterfly fragment exists, an indirect reduction technique is preferable to manual manipulations, which generate risk of soft-tissue stripping and devascularization of the fragment (Fig. 28.8
). The butterfly fragment in nondisplaced fracture lines is then secured with lag screws (Fig. 28.9
); this is the direct reduction portion of the case.
The remainder of the fixation is achieved using a 4.5-mm combination-hole plate. Because locked screws will not pull the plate to the bone, a locked place should be contoured anatomically (Fig. 28.10
). The plate is secured to the distal fragment with locking screws. The bone or undersurface of this particular plate has small undulations so that the plate contacts the bone or periosteum only at intermittent alternating points, allowing (as much as possible) preservation of the periosteal circulation. However, standard stainless-steel plates without the limited-contact feature and without the locking feature are also satisfactory choices. An experienced surgeon can bend and twist the plate during the procedure. Less experienced surgeons can precontour the plate by using a bone model or skeleton before the procedure and then sterilizing it (step 3).
In an alternate procedure, the locking plate may be applied initially on the distal fragment with a standard 4.5-mm cortical screw, which will pull the plate to the bone. Then a second locking screw can be placed to protect the initial screw. Any of the distal fragment holes can be used for the preliminary screw insertion.
A push-pull screw is then inserted 1 or 2 cm proximal to the plate. The AO articulating tension device is then applied at the proximal end of the plate and distracted (step 4, Fig. 28.2C
). If the plate is properly contoured, the plate need not be clamped to the shaft proximally. However, if necessary, the surgeon can carefully apply a bone clamp by making a small incision and laterally placing it with minimal stripping of soft tissue.
Figure 28.9. An intraoperative image demonstrates lag screw fixation of the butterfly and nondisplaced fracture fragments. The lag screws are placed through the periosteum with care not to strip additional bone. They should be placed so that they do interfere with plate placement. Note the nondisplaced, medial, malleolar fragment that will be secured with the plate.
Figure 28.10. A 4.5-mm tibial LCDC plate with combination holes is contoured for the distal-tibial medial surface with a distal bend and a proximal medial twist.
The fracture is then distracted (step 5, Fig. 28.2D
), and reduction is adjusted for angulation and rotation with small position changes in the extremity or with reduction clamps placed extraperiosteally (Fig. 28.11
). This is the indirect reduction portion of the case (5).
Once the fracture has been reduced, the articulating tension device is placed in the compression mode and compressed to approximately 60 kPa (step 6, Fig. 28.2D
) (7). This construct, with only one screw and the articulating tension device, is usually quite stable. This is a good time to obtain intraoperative radiographs for assessing fracture reduction and alignment. Standard overhead films or c-Arm images are obtained to assess the overall axial alignment and preliminary fixation (Fig. 28.12
). At this point in the procedure, any step is easily reversed.
If the reduction is satisfactory, then the major fragments should be secured with lag screws placed through or outside the plate. Additional screws are inserted into the plate to enhance stability (Fig. 28.13
) (step 7, Fig. 28.2D
). The exact number of screws is cannot be precisely predicted, but the surgeon should balance the fixation by dispersing the screws
equally on either side of the plate. Intraoperative radiographs are obtained and final fixation adjustments are carried out (Fig. 28.14
). The final radiograph should correspond closely with the preoperative drawing.
Figure 28.11. A. The contoured plate is slipped beneath the distal neurovascular structures and applied to the distal fragment with a single locked screw to create a fixed-angle plate. B. The ATD is then placed off a proximal push-pull screw and can be used to achieve distraction if necessary and to fine-tune the reduction. Clamps are used extraperiosteally to secure and fine-tune the reduction as well as to protect the lag screws during distraction and compression. Note the distal drill sleeve for insertion of a second, more distal, locking screw. The ATD creates a load-sharing construct between the implant and bone.
The wound is irrigated with antibiotic solution and closed over a small drain. The skin itself is approximated with interrupted, horizontal, mattress sutures of 4-0 nylon. No tension should be present at the skin edges at the time of closure (Fig. 28.15
). If tension-free closure cannot be obtained after osteosynthesis, then I prefer to make multiple, small, relaxing incisions with a no.10 blade on both sides of the surgical incision; this pie-crusting technique frequently allows closure without tension. If wound closure without tension is not possible, then only the portion of the wound that can be closed without tension is carried out, and the remainder of the wound is left open. The patient may then be returned to the operating room in several days for delayed primary closure or flap coverage if necessary.
A sterile nonadhesive dressing is applied over the wound, followed by application of a bulky Jones-type dressing. A splint may be incorporated into the Jones dressing if desired, particularly if more distal injuries are present (Fig. 28.16
); the splint also helps to prevent equinus deformity. Postoperatively, the limb is elevated on a Bohler-Braun frame for 1 to 3 days.
Diaphyseal tibial fractures are frequently accompanied by an associated fibular fracture, which usually does not require repair. However, if the tibia fracture is proximal or distal, plate osteosynthesis may be carried out at the time of tibial stabilization to enhance fracture stability. If the fracture results in excessive shortening, fibular osteosynthesis carried out before the tibial osteosynthesis may be additionally helpful. Care must be taken in preoperative planning to allow for satisfactory skin bridges between the tibial and fibular incisions, which should be kept to a minimum of 8 cm.