Name: Pilon Fracture ORIF with Anterolateral Tibia and Posterolateral Fibular Plating
Uploaded: 2017-06-20T00:00:00Z
Channel: Arthrex

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VPT1-00888-EN | B | Pilon Fracture ORIF with Anterolateral Tibia and Posterolateral Fibular Plating

Justin Fleming

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Pilon Fracture ORIF with Anterolateral Tibia and Posterolateral Fibular Plating

Hi, my name is Justin Fleming. I'm from Philadelphia, Pennsylvania, and today I'm going to walk you through a case example of fibular reconstruction utilizing the posterior lateral anatomic plates. And so this is the patient. She's a 32 year old female involved in a motor vehicle accident. She was a restrained driver. And this patient sustained a grade three open tibial plafond fracture and a concomitant fibular shaft fracture. These are the injury films at the time of presentation. You can appreciate that she has a valgus injury, but you can also appreciate that she has a short, comminuted fibula and there's an anterolateral translation of the articular block. And that really puts significant strain on the posterior medial corridor and increases the concern for neurovascular injury. And as typical protocol in stage one, we're essentially doing skeletal stabilization with an external fixator. And really the goal at this time is to improve the axial and rotational alignment in the length of the the affected limb. So specifically just trying to get the talus beneath the tibia, both the AP and lateral views. And so, unlike rotational ankle fractures where the talus routinely moves in the posterior lateral direction, oftentimes in fractures of the tibia, often the talus escapes anteriorly and the formation of the external fixator is this typical delta frame model. And so here we're using the ArthroFX system. And I just want to illustrate the mechanics of this. So you can see the radiolucent bars that are present there. And then through the calcaneal traction pin we can really drive the talus into a posterior anatomic alignment. And so these are the initial post-operative x rays. And you can appreciate that the length and the axial alignment has been restored. It's not uncommon to still have articular incongruity or potentially some shortening that that exists. Also I'd like I'd like you to notice that the external fixator is placed out of the zone of injury, and it's also outside of the zone of anticipated hardware placement. So when you're placing the device on stage one, you really have to be cognizant of stage two and have some sense of what your next surgical step might entail. And so this is the traction Cat scan, which is always done after the fixator is placed. And this is essentially our GPS, our roadmap into surgical reconstruction. So we can look here at fracture planes, incisional corridors, the order of reduction of the fracture fragments, order of hardware placement, and how we're going to get in to access and manipulate the fractures. I really do enjoy the 3D reconstructions. Just kind of gives me a mindset of of what the fracture looks like. And so tibial fractures typically have three major components. There's the medial malleolar fracture, the posterior volkmann's fracture and the tallo fracture. And certainly there can be secondary and tertiary injuries into each of those components. But this is really a very simple articular model. What is not uncommon is that there may be some arterial injury, and these generally are transient. But you can appreciate here on the CTA that the anterior tibial artery is entrapped in the anterolateral fragment. And so you want to be mindful of this during your dissection and hardware placement. So the first step on stage two is really for me is the restoration of the lateral column, especially in a valgus injury. I think that's important. As we stabilize the fibula and get it out to length, it improves the alignment of the distal tibial block by translating the talus, and then also via the connection of the anterior syndesmotic ligament, can produce a relative reduction of the the fracture. And you can see that this plate functions essentially in two ways. It is a posterior plate distally where we can deliver a high volume of fixed angle screws in the lateral malleolus, which typically has the worst bone stock, And then this plate twists around into a lateral projection. And then we can stabilize above the fracture. And you can see that also these comminuted fractures are quite difficult to get back together again, especially when you're fixing the fibula first. And having an anatomic plate certainly aids us in the reduction of some of these more difficult fibular injuries. Posterior plates really come in two flavors. There's essentially the posterior lateral plate which we just demonstrated. And you can see here Intraoperatively. Again, the real benefit is that it starts posteriorly. So we get the mechanical advantage. And then it wraps around laterally. And that really reduces the dissection in the posterior fibula as well. And then there's the posterior plate. And certainly this is really based on surgeon preference or potentially if you're using an all posterior incisional corridor to address the fracture with a patient in a prone position, this plate would be reasonable to use in that situation. The one caveat I think with posterior plating is really to understand the level of the superior peroneal retinaculum. You have to be careful. That's really the inferior dissection point when you're dissecting these fractures and placing the plate. So this slide really just demonstrates the the importance of maintaining a large skin bridge between the posterior incisions and your other ancillary incisions to fix the the tibial component. And so typically we need about 5.5cm. But again having posterior plates for posterior incision certainly makes sense mechanically. And then also through the appropriate incisional corridors. There's also another option for the posterior lateral plates. And I think this is probably more attuned for rotational ankle fractures. But there's also a syndesmotic tab that you can place a TightRope fixation through. And so I typically favor posterior plating and posterior approaches for rotational ankle fractures as well as plafond fractures. And for you for those of you that do this, you know, it's it's difficult to stabilize the syndesmosis from, from this vantage point. And often we're placing hardware outside the plate, which has its own subset of post-operative complications. So next we're on to the tibial component and we'll start on the medial column reduction. Again this is a valgus injury. So the forces on the medial side are really avulsive. And so this is a tension band screw. Essentially you try to get a large bicortical screw to improve the the pull out strength. And then we've added essentially a tension band plating. And you can see how that how well that reduces not only the medial component of the ankle, but also improves the alignment in the lateral component as well. And so here we're just reducing the the last of the talo fracture, which is typically in order of reduction of these injuries is is last. And we're just using a Steinmann pin to lever it down to improve the congruity of the lateral compartment of the ankle joint. And then that's stabilized with screws from medial to lateral. And then lastly, the workhorse of this whole construct is the lateral plate. And typically for valgus injuries I think they're going to if they go on to nonunion they'll fail back in valgus again. So my rule of thumb for these really is if I have a valgus injury they get an anterolateral plate. If they have a varus injury we use a medial plate. And the real benefits of this plate are that we can get, again, a high volume, a high density grafting screws, stabilizing screws right up right above the articular surface to stabilize the articular block to the to the tibial shaft, and then the final AP X-ray on the right. And then this is a seven month follow up. And I'll show you this because it's important, especially in a valgus injury that the fibula consolidates in my opinion. And so there's essentially no signs of hardware loosening or toggling. The lateral component is completely healed. And again the alignment is maintained which is really important. So it's not only the only the reduction of the deformity or the fracture of the time of surgery, but it's really having the hardware to maintain the reduction over the long period of time. So in summary, posterolateral plating certainly is advantageous in fibular reconstruction with a concomitant distal tubular plafond fracture. And one of the things that I really like about this plate is that it helps me to restore the anatomy in the segmental or comminuted fractures of the fibular shaft, which really can be difficult. And we can maintain the reduction by having a high density of fixed angle screws in the lateral malleolus, which typically has the the worst bone stock. And then lastly we have the ability to stabilize the syndesmosis. And I think the syndesmotic instability in rotational pilon fractures is probably under-recognized. And it's something that we probably should pay a little bit more attention to. Thank you.

Pilon Fracture ORIF with Anterolateral Tibia and Posterolateral Fibular Plating

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