Surgical Techniques for Complex Proximal Tibial Fractures

Selected

Instructional

Course Lectures

The American Academy of Orthopaedic Surgeons

PAUL TORNETTA IIIEDITOR, VOL. 61

COMMITTEEPAUL TORNETTA IIICHAIR

KENNETH A. EGOLMARY I. O’CONNORMARK PAGNANOROBERT A. HART

EX-OFFICIO

DEMPSEY S. SPRINGFIELDDEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY

FOR INSTRUCTIONAL COURSE LECTURES

Printed with permission of the American Academy ofOrthopaedic Surgeons. This article, as well as other lecturespresented at the Academy’s Annual Meeting, will be availablein February 2012 in Instructional Course Lectures, Volume 61.The complete volume can be ordered online at www.aaos.org,or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).

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Surgical Techniques for ComplexProximal Tibial Fractures

Jason A. Lowe, MD, Nirmal Tejwani, MD, Brad Yoo, MD, and Philip Wolinsky, MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Traditional and Alternative SurgicalApproaches to the Tibial Plateau:How to Select Them?Any surgical approach for fracture fix-ation should facilitate visualization offracture fragments and allow the appli-cation of optimal fixation devices andsoft-tissue repair. Treatment goals ap-plied to tibial plateau fractures includeanatomic articular surface reduction,restoration of the anatomic axis, andpreservation of the menisci. The ap-proach should not devitalize soft tissuesor cause further injury to surroundingstructures. An ideal surgical dissectionencompasses these principles and per-mits early joint motion.

The midline longitudinal incisionis the favored approach to the knee joint,as this incision facilitates knee replace-ment if needed in the future. Surgicalexposure for complex injuries (bicon-dylar fractures) requiring dual fixationneeds large medial and lateral flaps thatadd to soft-tissue complications. Othersurgical approaches allowing a moredirect approach to the fracture to de-crease the risk of soft-tissue injury from

excessive retraction or periosteal strip-ping are available. When one incisiondoes not adequately expose the fracture,it is better to use a dual incision than asingle midline exposure1-3.

Anterolateral ApproachThe anterolateral approach is used forthe most commonly seen tibial plateaufractures (Schatzker4 types I, II, andIII). It is also used for the lateral part ofa dual incision approach needed forinternal fixation of a bicolumnar frac-ture. The incision is centered onGerdy’s tubercle and is shaped as alazy S or a hockey stick. The fascia iselevated off the tibial tubercle to exposethe lateral tibial plateau. The kneecapsule is incised, and a submeniscalarthrotomy allows visualization of thearticular surface (Figs. 1 and 2). Inaddition to visualization of the articularsurface, this approach allows repair ofany meniscal tears.

Medial ApproachThe medial approach is used for amedial tibial plateau fracture (Schatzker

type IV) or as part of a dual approach tothe plateau. The incision parallels theposteromedial border of the proximalpart of the tibia. The pes anserinus iselevated, the fracture reduced, andfixation implants are placed beneaththe pes anserinus. The pes anserinusmay either be retracted (Fig. 3) orincised, with repair after fracture fixa-tion. The medial meniscus cannot beelevated as is possible with the lateralmeniscus; therefore, the limitation ofthis approach is the limited visualiza-tion of the articular surface of themedial plateau. Also, access to the pos-terior plateau is limited, but the medialapproach can be converted to a postero-medial approach.

Anterior Approach with Tibial TubercleOsteotomyThe advantage of the anterior approachwith osteotomy of the tibial tubercle isthat the tibial plateau and the intercon-dylar notch are completely exposed,allowing reattachment or primary su-ture of the cruciate ligaments5. Thisapproach is rarely used, and most

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of anyaspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of thiswork, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author hashad any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written inthis work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2011;93:1548-59

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TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 93-A d NU M B E R 16 d AU G U S T 17, 2011SU R G I C A L TE C H N I Q U E S F O R CO M P L E X

PR OX I M A L TI B I A L F R AC T U R E S

complex, bicondylar fractures are nowtreated with use of dual incisions.

Posteromedial ApproachMedial tibial plateau fractures extend-ing to the posterior aspect of the tibialplateau, posterior metaphyseal frac-tures, or those that require a buttresson the posteromedial cortex are bestfixed with use of the posteromedialapproach. Fragment-specific fixationof the medial plateau is recommendedover stabilization with a laterally basedlocking construct6. To obtain optimal

fixation of bicondylar fractures, a dualplating technique is recommended,with one plate fixing the medial frag-ment and one fixing the lateral plateau.Medial plateau fractures may be me-dial or posteromedial, with each re-quiring a plate to be, ideally, placed atthe apex of the fracture (fragment-specific).

The patient can be positionedprone or supine7. An incision is madeover the posteromedial aspect of theknee (Fig. 4). Dissection between themedial head of the gastrocnemius mus-

cle and the semitendinosus muscleallows exposure of the semimembra-nosus muscle, which is detached forbetter access to the posterior aspect ofthe tibia. Visualization of the articularsurface is limited, but, if necessary,visualization can be improved with alongitudinal split in the medial collat-eral ligament and capsule. Through thisincision, visualization of the articularcartilage can aid in congruent jointreduction.

Posterior ApproachAn isolated posterior shear fracture, aposterior cruciate ligament avulsionfracture with a large osseous fragment,or a posterior fracture dislocation is bestexposed with a posterior approach8,9. Az-shaped incision across the flexorcrease is used. The deep tissue planes arebetween the medial head of the gas-trocnemius and the semimembranosusmuscles or between the two heads of thegastrocnemius muscle with protectionof the neurovascular structures. Themedial or lateral head of the gastrocne-mius muscle may be partially detached,if it is necessary to improve exposure,enable fracture reduction, or insertfixation on the posterior rim.

Extended Lateral Approach withFibular OsteotomyThe Lobenhoffer approach is used toexpose fractures of the lateral tibialplateau that extend posteriorly when thehead of the fibula limits the exposure10,11.

The skin incision is made alongthe course of the peroneal nerve, pos-terior to the fibular head. After dissec-tion, the common peroneal nerve isprotected and an osteotomy of the fibulaat the junction of the head and neck isperformed, leaving the proximal at-tachments intact. This allows exposureof the tibial plateau from anterior toposterior.

Another way to approach theposterolateral plateau is without a fibu-lar osteotomy10. Absence of an osteot-omy makes it more difficult to visualizethe tibial fracture at the level of thefibular head; however, this approachis preferred as it avoids the risk of anonunion at the fibular osteotomy site.

Fig. 1

Clinical photograph of a patient’s right knee with the lazy-S incision used for internal fixation of a lateral

proximal tibial fracture.

Fig. 2

Clinical photograph of a patient’s right knee with retention sutures in the lateral meniscus (white

arrow) of a submeniscal arthrotomy.

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VO LU M E 93-A d NU M B E R 16 d AU G U S T 17, 2011SU R G I C A L TE C H N I Q U E S F O R C O M P L E X

PR OX I M A L TI B I A L FR AC T U R E S

Medial Tibial Plateau ReductionA shearing force produces a coronalplane fracture comprising approxi-mately 25% of the medial articularsurface12. This fragment is seen on alateral radiograph, but the full extent ofarticular involvement is best appreci-ated on sagittal computed tomography(CT) images. Since the medial collat-

eral ligament (MCL) prevents a sub-meniscal arthrotomy, reduction of themedial joint line is often obtainedindirectly with anatomic restoration ofthe medial cortex. If there is a questionabout the accuracy of the reduction ofthe articular surface of the medialplateau, a longitudinal incision is madein the MCL, where the fracture enters

the medial aspect of the joint. Ana-tomic reduction is confirmed byaligning the articular cartilage of eachfragment while the cortex is reducedwith a well-placed Weber clamp per-pendicular to the fracture. This white-white read of the medial plateauarticular cartilage augments accuracyof reduction.

Medial Plateau FixationSurgical stabilization of isolated me-dial plateau fractures (Schatzker typeIV) is accomplished with an under-contoured, nonlocking, flexible plate(1/3 T-plate or reconstruction plate)applied as a buttress. Fixation of themedial plateau in Schatzker type-VandVI fractures is more controversial.Stabilization can be accomplished withlocking screws placed through a later-ally based implant alone or stabilizedwith a medial plate as part of a dualplating construct (medial and lateralplate)13-17. Biomechanical and clinicaldata support both techniques. Al-though lateral-only locked plates re-duce surgical time, blood loss, andlimit soft-tissue stripping, a high rateof articular subsistence (26%) has beenreported13-17. Displacement of the me-dial fragment can result in knee in-stability, pain, and posttraumaticosteoarthritis12. The authors, there-fore, recommend fragment-specificfixation of the posteromedial and lat-eral plateau through a two-incisionapproach for bicondylar tibial plateaufractures. Fragment-specific fixation ofthe medial plateau avoids inadequatepurchase of the posteromedial frag-ment observed with lateral-only lock-ing screws6,16-18. The benefit of addedfracture stability is offset by greatersurgical time and higher postoperativeinfection rates. Current reports havedemonstrated postoperative infectionrates of 8.4% with dual plating com-pared with 1.6% with lateral-onlyfixation13,14. In the absence of a pro-spective, randomized, controlled trialcomparing these surgical approaches,the need for anatomic reduction of thejoint surface and adequate stabiliza-tion of the medial plateau takesprecedence.

Fig. 3

Clinical photograph of a patient’s left knee with a medial incision (patient’s head is to the left). The

tendons of the pes anserinus (white arrow) are seen over the clamp.

Fig. 4

Clinical photograph of a patient’s right knee. With the patient in the prone position, the solid line

identifies the level of the knee joint with the femur to the left. The dashed line illustrates an incision for

a posterior-medial incision.

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Lateral Plateau Articular ReductionHigh-energy bicondylar tibial fracturesare typically associated with articularsurface impaction of the lateral plateau.Successful restoration of the lateralaspect of the joint requires adequatevisualization and an array of reductiontechniques. A submeniscal arthrotomyand a laterally based femoral distractorimprove visualization of the articularsurface when needed. A single Schanzpin is placed into the femoral meta-physis, parallel to the joint line, and asecond Schanz pin is placed in the tibia,distal to planned plate placement lo-cation19. Care must be used withplacement of a lateral tibial pin so as tonot injure the neurovascular struc-tures of the anterior compartment20.Applying distraction opens the jointand enhances visualization of the lat-eral plateau. Retraction of the postero-lateral or anterolateral fragments(opening the door) can allow evenmore visualization.

Mobile articular pieces are re-duced with a dental pick or a small (0.45to 0.62-mm) wire and are temporarilystabilized with Kirschner wires. Im-pacted articular fragments must bemobilized from surrounding cancellousbone before they can be reduced. A 1/4

to 1/2 in (0.64 to 1.3-cm) osteotomeor bone tamp is used to elevate 1.0 to1.5 cm of cancellous bone with the ar-ticular segment. Once levered into po-sition, the fragment is stabilized withKirschner wires. With the impactedsegment reduced and secured with wirefixation, bone voids can be filled withgraft material and the lateral segmentcan be reduced (closing the door). Themedial and lateral plateaus can be re-duced and compressed with a periartic-ular reduction clamp19.

The contained defect of a puredepression fracture cannot be reducedwithout an osteotomy. If there is anincomplete fracture, the articular seg-ment is accessed by completing thefracture and reducing the articularfragment as described above. If there isno cortical fracture, articular reductionis done with one of two techniques. The

Fig. 5

Clinical intraoperative photograph of a patient’s left knee, demonstrating incisions for minimally

invasive plate osteosynthesis.

Fig. 6

Anteroposterior radiograph of a knee

illustrating the inability of locking

screws to reduce the valgus malalign-

ment in the coronal plane. As a result, a

valgus malunion, with the plate poorly

apposed to the tibia, is observed.

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Fig. 7

Fig. 8

Fig. 7 Anteroposterior and lateral

radiographs of an extra-articular

proximal tibial fracture demon-

strating the most common defor-

mities (valgus and procurvatum)

observed in these fractures. Fig. 8

Anteroposterior radiographs

showing how a medial starting

site produces a valgus deformity

as the intramedullary device en-

ters the tibial diaphysis.

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anterior compartment is released fromthe metaphyseal flare for both. Onetechnique is to use the DHS (DynamicHip Screw; Synthes, Paoli, Pennsylvania)set and fluoroscopic visualization. Theguidewire is directed from the lateraltibial metaphysis toward the impactedsegment. The cortex is then opened withthe cannulated 11-mm reamer from theDHS system. Bone tamps are introducedand used to tap the articular segmentinto place. The articular reduction isconfirmed by direct visualizationthrough the submeniscal arthrotomy.Alternatively, a lateral osteotomy ismade with drill holes (2.0-mm drill-bit) in a diamond pattern, with thedrill holes connected with use of a0.25-in (0.64-cm) osteotome. Thearticular segment is reduced as justdescribed. With either technique, thearticular fragments can be supportedwith Kirschner wires and bone graftprior to definitive fixation.

Lateral Plateau FixationSurgical stabilization of the lateralplateau must maintain reduction andrigid fixation of the articular segmentto a well-aligned tibial shaft. The jointsurface is stabilized with multipleparallel screws placed just beneaththe subchondral bone. These raftingscrews support the reduced articularsurface fragments and can be the prox-imal screws of a 3.5-mm or a 4.5-mm,precontoured periarticular plate or withminifragment (2.4 or 2.7-mm) screws.Minifragment screws and plates arefavored for articular comminutionwith fragments having minimal sub-chondral bone or when the proximalscrews in the precontoured plate arenot subchondral.

The articular segment is reducedto the shaft with traction (a manual orfemoral distractor). First, the plate isfixed to the proximal segment withbicortical screws (locked or nonlocked)inserted parallel to the joint21. The plateis reduced to the tibial shaft with abicortical screw or a so-called whirlybirdpush-pull type of device. It is importantto ensure that this does not malreducethe fracture in the coronal plane, andlocking screws should not be placed in

the distal segment until the alignment iscorrect22.

Minimally Invasive PlateOsteosynthesisThe proximal tibial anatomy and fracturepattern must be clearly understood ifprecontoured plates are used with mini-mally invasive techniques. The articularsurface is visualized with a small arthrot-omy, and percutaneous techniques areused for screw placement into the tibialshaft (Fig. 5). One must be careful whenthis technique is used for plates longerthan eleven holes, as the neurovascularbundles in the anterior and lateral com-partments are at risk12,23.

Locking ScrewsLocking screws increase construct ri-gidity, but they should be placedbicortically21,24. They are useful in se-verely osteoporotic bone, substantialmetaphyseal-diaphyseal comminution,

or short-segment periarticular and/orintra-articular fractures. Malunion hasbeen a problem, and it is necessary topay meticulous attention to fracturereduction before placement of lockingscrews (Fig. 6)25.

Intramedullary Nailing of ProximalTibial FracturesThe use of an intramedullary nail forfracture stabilization is appealing. Theinsertion point of an intramedullary nailis remote from the fracture site, mini-mizing vascular disruption of the fracturefragments, the implants are centrallylocated, and tibial diaphyseal fractureshave a high rate of union and low rate ofcomplications. As a result, the use ofintramedullary nailing for tibial fractureshas expanded from mid-shaft diaphysealfractures to proximal fractures26-32. In-tramedullary nail fixation is technicallymore demanding for proximal tibialfractures than for diaphyseal fractures.

Fig. 9

Lateral radiographs showing how an inferior starting site and posterior nail trajectory produce a

procurvatum deformity of the proximal segment as the nail enters the diaphysis.

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Fig. 10 Fig. 11

Fig. 12

Fig. 10 Anteroposterior radiograph demonstrating an

appropriate starting site, just medial to the lateral tibial

spine and in line with the mechanical axis. Fig. 11 Lateral

radiograph demonstrating a correctly selected starting

site and wire trajectory. The wire is just anterior to the

articular margin and directed parallel to the anterior tibial

cortex. Fig. 12 Anteroposterior and lateral radiographs

with a protection sleeve for a retropatellar tibial nail

centered at an appropriate starting site.

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Unlike intramedullary nailing of a di-aphyseal fracture, placement of the in-tramedullary nail does not reduce aproximal tibial fracture, and malreduc-tions of proximal tibial fractures withintramedullary nail fixation are reportedto be as high as 84%27,33-36.

The typical deformity caused byintramedullary nailing of proximal tibialfractures is valgus and apex anteriorangulation with anterior translation ofthe proximal fragment (Fig. 7). Thevalgus deformity is due to an imbalanceof muscle forces on the proximal frag-ment and is accentuated when theinsertion point is too medial or directedlaterally. The tip of the nail can abut thelateral cortex causing the proximalfragment to rotate into a valgus position(Fig. 8)34,35,37. The apex anterior deformityresults from a combination of the pull ofthe patellar tendon34, a distal insertionsite, or a posteriorly directed nail thatdeflects off the posterior tibial cortex androtates the proximal fragment (Fig. 9).Nails with an accentuated distal Herzogbend may translate the proximal frag-ment anteriorly, described by Henleyet al. as the wedge effect38.

To prevent malalignment ofproximal tibial fractures during intra-medullary nailing, one should properlyplace the starting point; reduce thefracture prior to guidewire placement,reaming, and nail insertion; and holdthe reduction until all of the lockingbolts have been inserted.

The Proper Starting PointFluoroscopic imaging is used to obtaingood anteroposterior and lateral C-armimages of the knee. The starting pointon the anteroposterior radiograph is inline with the medial border of the lateraltibial spine (Fig. 10). The insertion siteon the lateral radiograph is slightlyanterior to the anterior margin of thearticular surface. The guidewire and nailare inserted as parallel to the anteriorcortex as possible (Fig. 11).

Fracture Reduction TechniquesExtended Leg PositionIt is critical to reduce the fracture andmaintain the reduction during fracturefixation. The intraoperative position of

the leg affects fracture reduction. Whenthe knee is maximally flexed, whichfacilitates collinear insertion of the nail

with the anterior tibial cortex, the pull ofthe patellar tendon increases the apexanterior deformity. When this occurs, the

Fig. 13

Anteroposterior and lateral radiographs with a proximal Schanz pin for the AO distractor, appropriately

placed parallel to the articular surface (left) and posterior to the nail path (right).

Fig. 14

Anteroposterior and lateral radiographs demonstrating an appropriately placed distal Schanz pin

inserted parallel to the ankle joint and posterior to the nail path.

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apex deformity can be limited by placingthe instrumentation in the leg withminimal knee flexion39. Originally, semi-extended nailing was performed througha large medial parapatellar incision;however, it can now be done with a smallsuprapatellar incision. The instrumentsand nail are passed through protectivesleeves, posterior to the patella to theproximal part of the tibia (Fig. 12)16.Recent studies have suggested this tech-nique can be used without injury to thepatella or femoral articular cartilage, themenisci, or the anterior cruciate liga-ment16,18,40. No outcomes data are avail-able for this technique.

Use of a Femoral Distractor or anExternal Fixation FrameA universal distractor or an externalfixator can be used to obtain andmaintain fracture reduction. With useof fluoroscopic imaging, a proximalSchanz pin is inserted from the medialside of the proximal part of the tibiaposterior to the planned intramedul-lary nail path (Fig. 13), and a distalSchanz pin is placed medially in theposterior malleolus (behind the nail) orat the level of the physeal scar (Fig. 14).The pins should be inserted parallelto the proximal and distal joint lines.Application of traction through theframe until the pins are parallel typi-cally results in adequate reduction34,41.

Temporary Plate FixationA small plate can be used as a temporaryreduction device29,42. The plate may beplaced on the medial or lateral tibialborder, but the medial border is bettersince the medial side of the fracture isoften less comminuted. The medialincision is positioned posterior to theposterior borders of the tibia so that ifthe incision fails to heal, no bone will beexposed (Fig. 15). Minimal deep dis-section is needed, and the plate is placedover intact periosteum. Unicorticalscrews are used so the reamer and nailcan pass. After insertion of the nail andall interlocking screws, the plate may beremoved or the screws on the proximalside of the fracture may be taken out.The plate then acts as a buttress con-struct, preventing a deformity from

recurring while permitting relative mo-tion at the fracture site.

Blocking ScrewsSo-called blocking or Poller screws canbe used during intramedullary nailingof proximal tibial fractures. They areplaced preemptively in an effort toprevent a deformity or as a so-calledbailout after deformity has occurred.They are used to narrow the canal, tocreate a path, or as an artificial cortexfor the nail to pass down28,33,43.

Blocking screws are inserted per-pendicular to the plane of the deformity,on the concave side of the deformity,within the more mobile fracture segment.For example, with a valgus deformity, thescrew is placed from anterior to posterior,on the lateral side of the instrument path,and in the proximal segment (Fig. 16).

The screw functions as a so-called artifi-cial cortex.

Blocking screws can also be usedfor an anterior malalignment. Theblocking screw is placed slightly poste-rior to the midline, from medial tolateral, in the proximal fragment (Fig.16). As a nail is inserted, it contacts theblocking screw, extending the proximalfragment and decreasing the apex ante-rior deformity. The screw should not beplaced in the midline since nail passagemay be blocked by the screw.

Percutaneous ClampsThe orientation of a fracture line mayallow percutaneous placement of areduction clamp to obtain and maintainthe reduction (Fig. 17). The use ofclamps has not been shown to increaseinfection rates44.

Fig. 15

Anteroposterior and lateral radiographs with a provisional locking plate on the posteromedial tibial

cortex. Unicortical locking screws are used so as to not obstruct insertion of reamers or the intra-

medullary implant.

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Implant SelectionIt is important to know the implants inorder to ensure that at least two lockingscrews can be placed in the proximalsegment. The distance from the end ofthe nail to the locking bolts determineshow far proximal or distal fracture linescan extend and still be stabilized by theintramedullary nail. The number andorientation of the proximal and distalinterlocking bolts vary by implant.Oblique bolts have demonstrated morestability than transverse bolts in resist-ing coronal plane deformity, but notaxial or torsional stability38. The com-bination of oblique and transverseinterlocking screws increases constructstability45,46. Intramedullary deviceswith a distal Herzog bend may accen-tuate a sagittal plane deformity because,as the Herzog bend contacts the pos-terior cortex, it can create a so-calledwedge effect and translate the proximalsegment anteriorly (Fig. 18)38.

Complications and PitfallsKnee pain, after intramedullary nailingof the tibia, affects 60% to 70% ofpatients47-50. The anterior knee pain isexacerbated by kneeling, squatting, stairclimbing, or high-performance athleticactivities. Implant removal after fractureunion has had inconsistent results withregard to relieving anterior knee pain.There is no difference in the prevalenceof knee pain when a transpatellar orparapatellar incision is used.

The prevalence of malunion hasbeen reported to be as high as 84%36.With use of the techniques described inthis article, malunion rates have beenreduced to between 8% and 23%28,29,31.Strict attention to surgical techniqueand the use of reduction aids decreasethe prevalence of malreduction.

Infections and nonunions aremost commonly associated with openand/or comminuted fractures29,31,36,42,51.Ultimate union rates of 91% to 100%

have been reported, but the union ratefollowing primary fixation is approxi-mately 77%28,29,36,42. Lindvall et al. re-ported a 100% union rate for closedtibial fractures and a 23% rate of non-union for open fractures stabilized withan intramedullary nail31.

Patient-specific contraindications tothe use of an intramedullary nail includeopen physes, intramedullary canals toonarrow to allow insertion of a nail, pre-existing canal deformities, knee contrac-tures, and so-called blocking hardwaresuch as an ipsilateral knee replacement orknee fusion. Fracture-specific contraindi-cations to the use of an intramedullary nailinclude substantial intra-articular in-volvement, and short extra-articular seg-ments that preclude placement of at leasttwo interlocking screws6.

Nails Compared with PlatesA literature meta-analysis found a trendtoward an increased prevalence of mal-union after intramedullary nailingcompared with plate and screw osteo-synthesis (p = 0.06), but a lower infec-tion rate after intramedullary nailing(p < 0.05)52. Lindvall et al. also demon-strated a trend toward a higher mal-union rate for intramedullary nailing(p = 0.103), a threefold increased rate ofhardware removal after plate and screwfixation, and no difference in implantfailure between these two techniques31.Both intramedullary nails and plates canbe inserted with use of surgical tech-niques that respect the local soft-tissuebiology. These techniques optimizefracture-healing and contribute to ahigh rate of fracture union for bothoperative procedures27,29,52,53.

Implant failure has been reportedfor both intramedullary nails andplates35,36,53. Early studies of intramedullarynails had implant failure rates as high as25%, while only 2.6% of plates failed36,53.Many early failures of intramedullary nailsinvolved small-diameter locking bolts24.More recent literature has demonstratedsimilar prevalences of implant failure forintramedullary nails and plates2,28,31,34,54,55.

OverviewExtra-articular proximal tibial fractures aretechnically demanding fractures to treat.

Fig. 16

Anteroposterior and lateral radiographs demonstrating proper positioning of blocking screws to aid in

fracture reduction and strengthen the implant construct. Anterior-posterior screws placed lateral to

the nail (white large arrows) prevent valgus deformation, and medial-lateral screws placed posterior to

the nail (white small arrows) prevent procurvatum.

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Fixation with an intramedullary nail re-quires a firm understanding of the anat-omy of the proximal part of the tibia, thefracture pattern, the deforming forces, andthe implant system. The prevalence ofmalreduction can be reduced with use ofmeticulous surgical technique, a correctnail insertion site, and adjuvant reductionaids. The rates of postoperative infectionand nonunion are related more to thenature of the injury (open and com-minuted) than to the implant. Patientsshould be educated on the occurrenceof postoperative functional knee pain,

which seems to occur more commonlyin younger, more active patients.

Jason A. Lowe, MDUniversity of Alabama at Birmingham,510 20th Street South, FOT 960,Birmingham, AL 35294

Nirmal Tejwani, MDNYU Orthopedic Surgery Associates,301 East 17th Street, Suite 1403,New York, NY 10003

Brad Yoo, MDPhilip Wolinsky, MDDepartment of Orthopaedic Surgery,University of California Davis,4860 Y Street, Suite 1700,Sacramento, CA 95817

Printed with permission of the AmericanAcademy of Orthopaedic Surgeons. This article,as well as other lectures presented at theAcademy’s Annual Meeting, will be availablein February 2012 in Instructional CourseLectures, Volume 61. The complete volumecan be ordered online at www.aaos.org, or bycalling 800-626-6726 (8 A.M.-5 P.M., Central time).

References

1. Barei DP, Nork SE, Mills WJ, Coles CP, Henley MB,Benirschke SK. Functional outcomes of severebicondylar tibial plateau fractures treated with dualincisions and medial and lateral plates. J Bone JointSurg Am. 2006;88:1713-21.

2. Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ.Staged management of high-energy proximal tibia frac-

tures (OTA types 41): the results of a prospective, stan-dardized protocol. J Orthop Trauma. 2005;19:448-56.

3. Georgiadis GM. Combined anterior and posteriorapproaches for complex tibial plateau fractures.J Bone Joint Surg Br. 1994;76:285-9.

4. Schatzker J, McBroom R, Bruce D. The tibialplateau fracture. The Toronto experience 1968-

1975. Clin Orthop Relat Res. 1979;138:94-104.

5. Fernandez DL. Anterior approach to the knee withosteotomy of the tibial tubercle for bicondylar tibialfractures. J Bone Joint Surg Am. 1988;70:208-19.

6. Barei DP, O’Mara TJ, Taitsman LA, Dunbar RP,Nork SE. Frequency and fracture morphology of the

Fig. 17 Fig. 18

Fig. 17 Lateral intraoperative radiograph with a Weber clamp placedpercutaneously to hold the reduction during nail insertion. Fig. 18 Lateral intraoperative

radiograph with a well-positioned guidewire (parallel to the anterior cortex) during reaming (left). Insertion of a nail with a low Herzog bend (black arrow)

showing displacement of the proximal fragment as it contacts the posterior cortex (right).

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Surgical Techniques for Complex Proximal Tibial Fractures

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