TIBIA OSTEOSYNTESIS

The first reports on modern techniques of internal fixation are however only about 100 years
old. The brothers Elie and Albin Lambotte from Belgium have described in detail the essentials
of what they called “osteosynthesis” of fractures with plates and screws, wire loops and
external fixators.
The ultimate goal of operative fracture fixation is to obtain full restoration of function of the
injured limb and the patient to return to his preinjury status of activities, as well as to minimize
the risk and incidence of complications. The purpose of the use of implants is to provide a
temporary support, to maintain alignment during the fracture healing, and to allow for a
functional rehabilitation.
Every fracture is associated to a certain extent with an injury to the tissues surrounding the
bone. The energy, direction, and concentration of forces inducing the fracture will determine
the fracture type and the associated soft tissue lesions.

The type of tibia fracture and the treatment

1. Spiral Fracture
2. Complex Fracture
Preoperative Planning on Paper
Instrument:
Surgical Approaches
Tibia is large, transmits most of the stress of walking, and has a broad, accessible
subcutaneous surface

There are two main tibial approaches:

1. The anterior approach is used most often because it affords easy access to the
subcutaneous surface of the bone.
2. The posterolateral approaches is rarely used but can save the limb when skin
breakdown has made anterior approaches impossible. This approach is commonly
used for bone grafting for nonunited fractures.

Three surgical approaches are described for access to the tibial plateau:

The anterolateral and posteromedial approaches are often used together to treat
complex proximal tibial fractures. The minimal access anterolateral approach to the
tibial plateau utilizes two windows of the anterolateral approach.
The minimal access approach to the distal tibia is used for percutaneous plating of
multifragmentary fractures of the distal tibial metaphysis.
The majority of tibial shaft fractures treated operatively are treated by the insertion of
intramedullary nails. The minimal access approach for tibial nailing is used in this
technique

Anterolateral Approach to the Lateral Tibial Plateau

The anterolateral approach to the lateral tibial plateau offers safe access to the lateral tibial
plateau for:

 Open reduction and internal fixation of fractures of the lateral tibial plateau Bone
grafting for delayed union and nonunion of fractures Treatment of osteomyelitis
Excision and biopsy of tumors
 Proximal tibial osteotomy
 Harvesting of bone graft

Position of the Patient

Place the patient supine on a radiolucent table. Place a firm wedge beneath the knee to flex
the joint to approximately 60º (Fig. 11-1). Place a small bag underneath the buttock to
correct the normal external rotation of the lower limb. This will ensure that the patella is
facing directly anteriorly.
Exsanguinate the limb either by elevating it for 3 to 5 minutes or by applying a soft rubber
bandage.

Then inflate a tourniquet.

Landmarks and Incision

Landmarks

Palpate the shaft of the proximal tibia along its anterior border. Identify the position of the
lateral joint line of the knee by flexing and extending the joint. Palpate Gerdy's tubercle just
lateral to the patella tendon. All these landmarks are easily palpable, even in an obese patient.

Incision

Make an S-shaped incision. Start approximately 3 to 5 cm proximal to the joint line, staying
just lateral to the border of the patella tendon. Curve the incision anteriorly over Gerdy's
tubercle and then extend it distally, staying about 1 cm lateral to the anterior border of the
tibia.

Internervous Plane
There is no internervous plane in this approach. The dissection is essentially epi-periosteal
and does not disturb the nerve supply to the extensor compartment.
Superficial Surgical Dissection
Deepen the incision proximally through subcutaneous tissue to expose the lateral aspect of
the knee joint capsule. Incise the knee joint capsule longitudinally down to the superior border
of the lateral meniscus. Take care not to divide the lateral meniscus inadvertently. Below the
joint line, deepen the incision through subcutaneous tissue and incise the fascia overlying the
tibialis anterior muscle (Fig. 11-3).
Deep Surgical Dissection

Proximally enter the knee joint by dividing the synovium. Carefully detach the lateral meniscus
from its soft-tissue attachments inferiorly and develop a plane between the undersurface of
the lateral meniscus and the underlying tibial plateau. Insert stay sutures to the periphery of
the meniscus to facilitate reattachment during closure. Ensure that the anterior attachment of
the meniscus remains intact. Detach a sufficient amount of the meniscus to allow adequate
visualization of the superior surface of the lateral tibial plateau. Using an elevator, inferiorly
detach some of the origin of tibialis anterior from the proximal tibia. Try to work in a plane
between the periosteum and the muscle (Fig.11-4).

Dangers

Nerves
The superficial branch of the peroneal nerve has a variable course. Normally, it lies well
posterior to the area of dissection and it should not be injured. The lateral meniscus has to be
detached from some of its soft-tissue attachments inferiorly to allow adequate visualization of
the articular surface of the tibia. Take care not to completely detach it, preserving anterior and
posterior attachments, however. It is at most risk during the incision of the knee joint synovium.

How to Enlarge the Approach

Local Measures
Application of a distractor or external fixator to the lateral aspect of the knee between the
femur and the tibia allows a varus distraction force to be applied to the knee joint, thereby
opening up the lateral compartment.

Extensile Measures
Proximal Extension. To extend the approach proximally, continue the skin incision along the
lateral aspect of the patella, then curve posteriorly over the lateral aspect of the distal femur.
Deepen the incision through the lateral joint capsule to gain access to the knee joint and the
distal femur proximally.
Distal Extension. To extend the approach distally, continue the incision in a longitudinal
fashion, remaining 1 cm lateral to the anterior border of the tibia. Extend it all the way down to
the ankle proximally. Deep dissection, either by splitting the tibialis anterior muscle or by
detaching it from the lateral aspect of the tibia, allows access to the tibial shaft down to its
proximal quarter.

Minimal Access Anterolateral Approach to the Proximal Tibia

The minimal access anterolateral approach offers safe access for open reduction and internal
fixation of proximal tibial fractures. The approach is of most use in treating fractures, which do
not involve the joint surface, or where reduction and fixation of the intra-articular element of
the fracture can be carried out without formal exposure of the joint surface. Precontoured
plates are easy to use along the lateral aspect of the proximal tibia and can be applied
percutaneously. As with the anterolateral approach to the proximal tibia, the soft tissues in this
area are critical, and massive swelling or blistering are contraindications to immediate surgery.
Position of Patient
Place the patient supine on a radiolucent table, as for the anterolateral approach, to the lateral
tibial plateau (see Fig. 11-1).
Landmarks
Palpate the shaft of the proximal tibia up to the joint line and identify Gerdy's tubercle just
lateral to the patella tendon. Confirm the position of the joint line by flexing and extending the
knee.
Incision
Two incisions are made. Proximally, begin the incision just proximal and lateral to Gerdy's
tubercle and extend it distally in a curvilinear fashion for approximately 5 cm to 6 cm. Distally
make a 5- to 6-cm longitudinal incision approximately 2 cm lateral to the tibial crest and parallel
with it. The size and length of the distal window depends on the pathology to be treated and
the implants to be used. The position of the incision often can only be assessed using the
image intensifier control (Fig. 11-5).
Internervous Plane
There is no internervous plane in this approach. The dissection is epi-periosteal and
submuscular and does not disturb the nerve supply to the extensor compartment (superficial
peroneal nerve).
Superficial Surgical Dissection
Proximally incise the deep fascia in the line of the skin incision to access the proximal tibia.
Retract the tibialis anterior muscle laterally and distally, preserving as much soft tissue as
possible.
Distally deepen the approach in the line of the skin incision through subcutaneous tissue, then
incise the deep fascia in the line of the skin incision (Fig. 11-6).
Deep Surgical Dissection
Proximally strip the soft tissues off the proximal tibia to allow adequate visualization of the
pathology and placement of implants. Try to preserve as much soft-tissue attachments to the
bone as possible. Distally develop a plane between the tibialis anterior muscle and the lateral
border of the tibia. This can easily be achieved with blunt dissection using the Cobb elevator.
Finally, develop an epi-periosteal plane to connect the two incisions running along the lateral
border of the tibia by using a blunt elevator (Fig. 11-7).
Dangers
The superficial branch of the peroneal nerve should be posterior to the proximal dissection.
The course of the nerve is variable, thus care must be taken during the superficial surgical
dissection to ensure that the nerve is not damaged.

How to Enlarge the Approach

Locally
The two windows can be connected, and further dissection of the origin of tibialis anterior from
the lateral aspect of the tibia allows visualization of the lateral aspect of the whole proximal
third of the tibia.
Posteromedial Approach to the Proximal Tibia
Complex fractures of the proximal tibia often involve a large posteromedial fragment. Accurate
reduction of this fragment onto the tibial shaft is critical to allow reconstruction of the joint.
Plates applied to the posteromedial aspect of the tibia prevent varus deformity, the most
common deformity of the proximal tibia after fracture. Biomechanically, these plates are on
the compression side of the bone. Another potential advantage of the incision is that the skin
and soft tissues on the posteromedial aspect of the tibia are usually free from blisters that
commonly occur on the anterior portion of the tibia. However, if the soft tissues on the
posteromedial aspect of the proximal tibia are poor, surgery must be delayed until the soft-
tissue conditions have improved.
The indications for this approach include:
Open reduction and internal fixation of fractures of the medial tibial plateau

Open reduction and internal fixation of complex bicondylar tibial plateau fractures
Surgical Exposures in Orthopaedics: The Anatomic Approach, 4th Edition 2009
Upper tibial osteotomy
Drainage of abscess
Biopsy of tumors
Reference

1. Solomon, L, et all. 2010. Apley,s System of Orthopedic and Fracture 9th Edition. London:
Hoder Arnold
2. Brown, Charles M Court, et all. 2015. Rockwood and Green’s: Fracture in Adult 8th
Edition. Philadelphia: Lippincott William and Wilkins.
3. Hopenfeld, Stanley, et all. 2009 Surgical Exposure in Orthopedic: The Anatomic Approach
4th Edition. Philadelphia: Lippincott William and Wilkins