As is the case with tibial plateau fractures, these injuries occur close to the joint and must be treated with the cartilage surface of the ankle joint in mind. Case Presentation A 66-year-old woman had sustained a car crush injury 3 h prior to her presentation to our hospital. Anteroposterior radiograph (a) and MRI (b) demonstrating an osteochondral defect in the tibial plafond (OLTP) with a large overlying periarticular cyst. Posteromedial Reversed L-shaped Approach for Posterior Column Tibial Pla... Feat. Anterolateral Approach for Tibial Pilon Fractures David J. Hak, MD, MBA H igh-energy tibial pilon fractures present signifi - cant challenges. Tibial plafond fractures occur just above the ankle joint and involve that critical cartilage surface of the ankle. Often this presents with a failure into valgus on injury films. Clinically, isolated PL quadrant tibial plateau fractures were treated via an anterolateral supra-fibular-head approach and lateral rafting plate fixation. Example 2 . was managed surgically through a combined angiosome- or perforator-sparing anterolateral approach Figure 1. A valgus defor-mity, swelling and tenderness in the right knee were found on physical examination. The approach was characterized by direct handling PM and PL fragments of posterior tibial plafond through three different anatomic planes in supine position. Since the anterior compartment muscles arise from the anterior fibula, the incision is usually not extended more than seven centimeters above the ankle joint. It was worth noting that the sufficient length of the minimum distance of 7cm between the incisions was applied, which avoid ischemic necrosis of the skin bridge and wound complications. This approach is These are considered to represent 1-10% of all lower limb fractures 6. Due to this reason, the anterolateral approach is the most frequently used surgical approach for tibial plateau fractures. Which of the following nerves is MOST at risk during an anterolateral incision and exposure of … the anterolateral approach to deal with a tibial plateau fracture (Schatzker III) in detail. Fractures of the foot, tibial shaft, or fibula should be evaluated. Proximally, the entire anterior compartment musculature, including the peroneus tertius, can then be mobilized and retracted medially. A pilon fracture is a type of distal tibial fracture involving the tibial plafond. It should be identified, mobilized, and protected throughout the surgical procedure. 10 anatomy and PatHoPHysiology The distal tibial physis con-tributes 50% of tibial growth and approximately 0.25 inches (4-6 mm) of longitudinal growth per year.11,12 However, the incision requires J Orthop Trauma. To expose the joint make a horizontal capsulotomy between the deep edge of the meniscus and the tibia. Courses, webinars, and online events, in your region or worldwide, Pediatric distal femur module is now online, Anterior and anterolateral partial articular pilon fractures, Some extraarticular distal tibia fractures stabilized with a submuscular anterior compartment plate. Make a straight incision lateral to the patella. In contrast, an anterolateral approach to the tibial plafond allows direct access to the Tillauxe Chaput fragment, but provides suboptimal access to the medial side [18, 19]. Mean age was 46 years (range, 19 to 75), and the mean follow-up period was 25 months (range, 14 to 50). Full-length images of the tibia and fibula complete the radiological examination of the injured leg. The diagnosis was defined as lateral tibial plateau fracture of the right knee (Schatzker III). Avoid the peroneal nerve which runs posterior to the biceps femoris tendon at its attachment to the fibular head. Severe plafond - large medial fragment - characteristic Tillaux / syndesmotic fragment - articular fragments driven up into joint - both columns disrupted . The anterolateral approach is indicated for pilon fractures that involve the lateral column. Anterolateral Approach Because most tibial plateau fractures involve thelateral tibial plateau, an anterolateral approach is the most frequently used approach for the treatment of plateau fractures ( Figs. The approach was characterized by direct handling PM and PL fragments of posterior tibial plafond through three different anatomic planes in supine position. Release the proximal attachment of the tibialis anterior muscle. Footnote: (a) An illustration in the mid-sagittal plane is demonstrating the involved anterior joint capsule (circle) with associated osteophytes from the anterior tibial plafond and anterior talar neck. The anterolateral approach is then made in line with the fourth ray of the foot and extends proximally in line with the fibula. The lateral tibial plateau is exposed through a conventional anterolateral approach. Distally, the incision can extend as far as the talonavicular joint. Caution Do not attempt to expose the postero-medial side of the tibia from the antero-lateral approach. Materials and Methods: This retrospective and prospective study analyzes the functional outcome of Anterolateral distal tibia LCP for treatment of distal tibia fracture. We retrospectively reviewed 28 ankles with AO/OTA type C pilon fractures that were treated using the anterolateral approach combined with medial MIPO. This nerve invariably crosses the surgical incision proximal to the ankle joint. 2.1 Anterolateral approach Lateral tibial plateau fractures are very common. Diagnosis is usually made on a CT scan or magnetic resonance imaging (MRI) [2, 6]. An anterolateral approach is used to obtain plate fixation as shown in Figure A. For distal tibial fractures, Bohler's anterolateral approach allows better visualization of the distal tibial joint surface and fixation of the tibia and fibula with a single distal anterolateral incision 13, 14. Proper location of the arthrotomy, preplanned to lie over the fracture, is critical to avoid unnecessary and damaging devascularization of fracture fragments. The pin placement in the talar neck, which is anterior to the axis of rotation of the talus, will produce ankle joint distraction and plantarflexion, maximizing articular visualization. Fig. If necessary release the ilio-tibial tract by incising it or taking a small flake of bone from Gerdy’s tubercle. Make a straight incision lateral to the patella. Open the deep fascia anterior to the ilio-tibial tract. 1–4). DEFINITION Distal tibia fractures are primarily located within a square based on the width of the distal tibial metaphysis. For selected cases, with a significant compromise of the posterolateral and anterolateral quadrants of the tibial plateau, including the tibial spines, the extended anterolateral approach may be complemented by a planned detachment of the anterior horn of the lateral meniscus. After sterilization of the surgical f … Surgical Technique of Anterolateral Approach for Tibial Plateau Fracture Orthop Surg. (b, c) Sagittal fluid-sensitive MR images are showing a superior talar neck (arrows) and anterior tibial osteophytes (dashed arrows) in a male with anterior ankle impingement symptoms. The anteromedial approach is used for OTA 43B and C fractures and allows access for medial and anterior hardware placement especially when the posterolateral (Volkman) is the constant fragment. 11 DePuy Synthes LCP Anterolateral Distal Tibia Plate 3.5 Surgical Technique 2 Reduce articular surface Optional instrument 394.350 Large Distractor 395.490 Medium Distractor Approach A … A second 4 mm Schanz pin is placed from lateral to medial at the tibia, proximal to the anticipated plate application. After submeniscus arthrotomy, the comminuted lateral plateau is … Plating on the lateral surface of tibial plafond is a new entity and the anterolateral approach is gaining popularity for the fixation of tibial pilon fractures. The fascia of the extensor digitorum brevis can be incised, with the muscle carefully dissected and retracted medially. 34.10 ) . Many fractures of the tibial plateau can be treated with an anterolateral approach to the proximal tibia. DOI: 10.1097/BOT.0b013e3181e5e17d Corpus ID: 205491525 A New Posterolateral Approach Without Fibula Osteotomy for the Treatment of Tibial Plateau Fractures @article{Frosch2010ANP, title={A New Posterolateral Approach Without Fibula Osteotomy for the Treatment of Tibial Plateau Fractures}, author={Karl-Heinz Frosch and P. Balcarek and T. Walde and K. … Application of a distractor intraoperatively greatly assists with articular visualization. The fascia over the anterior compartment of the distal tibia is incised sharply, beneath the superficial peroneal nerve. The anterolateral approach to the tibia has been popularized for management of tibial pilon fractures. With permission.) The anterolateral approach to the tibia has been popularized for management of tibial pilon fractures. If this approach is used in a staged fashion, when the soft envelope is ready, it affords excellent visualization for fracture fixation through thick skin flaps. approach difficulty is encountered in visualization of the Chaput fragment [10, 11]. This video reviews the indications, surgical approach, and case examples of the anterolateral approach to a distal tibial plafond fracture. An osteotomy anterolateral approach for lateral tibial plateau fractures merged with relatively simple and intact posterolateral corner displacement De-peng Meng , # 1 Tian-wen Ye , # 1 and Ai-min Chen 1 Utilizing standard anteromedial and anterolateral portals, a diagnostic evaluation should be performed as described by Ferkel to evaluate for associated pathologies []. Case Presentation A 66-year-old woman had sustained a car crush injury 3 h prior to her presentation to our hospital. 3. The purpose of this study was to compare the efficacy of anterolateral distal tibial locking plates in capturing main fracture fragments in tibial plafond fractures. The three radiographic views show a distal tibial complete articular fracture. Mechanism Typically high energy injuries and occur as a result of an axial loading which. Take care not to damage the superficial peroneal nerve which lies directly beneath the skin. Plating on the lateral surface of tibial plafond is a new entity and the anterolateral approach is gaining popularity for … ANATOMY Internal rotation of distal tibia 4. BACKGROUND Although the initial description of the tibial pilon fracture treated with open reduction and internal fixation (ORIF) demonstrated excellent surgical outcomes with minimal complications, 1 subsequent reports of their treatment held tempered enthusiasm. A tibial plafond fracture (also called a tibial pilon fracture) occurs at the end of the shin bone and involves the ankle joint. Ankle impingement syndrome is a syndrome that encompasses a wide range of anterior (anterolateral and anteromedial) and posterior (posteromedial) ankle joint pathology causing painful mechanical limitation of full ankle range of motion secondary to both osseous and soft tissue abnormalities 1).Location of pain is referenced from the tibiotalar (talocrural) joint 2). anterolateral approach to the proximal tibia is used. The results and complication rate between anteromedial and anterolateral approach for open reduction and internal fixation of these fractures were compared. The anterolateral approach to the tibia has been popularized for management of tibial pilon fractures. METHODS: From May 2011 to Dec 2015, 169 OTA C-type pilon fractures met inclusion and exclusion criteria with computed tomographic (CT) scans performed prior to definitive fixation. Close the remaining soft tissues in a routine manner. Very posterior lesions can be addressed via a posterior arthroscopic approach described by Van Dijk … The anterolateral approach to the distal tibial plafond fracture is indicated for fracture with anterior and/or lateral comminution and/or impaction. The knee joint should also be evaluated for soft tissue damage or bony disruption. 1–4). Materials and Methods: This retrospective and prospective study analyzes the Even with proper treatment, there can be both short and long-term complications of ankle joint function. Anteromedial Approach. 9.1. Supine position was set up and a pad was put under the affected hip. The other major factor that must be considered with these injuries is the soft-tissue around the ankle region. Initial anteroposterior (AP), mortise, and lateral radiographs are obtained. Skin incision. - small anterolateral approach - joint reduction and cannulated screw from Tillaux fragment medially - medial percutaneous plate . Anterolateral Approach for Reduction of Tibial Pilon Fractures The anterolateral approach ( Fig. Their results could be improved by following the new guidelines for the management, and modern plating techniques. Advantages also include good soft tissue cover, ability to get to both tibia and fibula and if there is an open wound on the medial side. 3. The epidemiological data, operation details, and clinical outcomes over 26.4 ± 2.3 months (range 24–30 months) of follow-up were prospectively collected and analyzed. Courses, webinars, and online events, in your region or worldwide, Pediatric distal femur module is now online. The anterolateral approach is the mostly used to treat tibial plateau fractures in the clinic. Ankle impingement syndrome. 51. The anterolateral approach is useful for: The anterolateral approach offers excellent visualization of the tibial articular surface as far as the medial malleolus, while avoiding dissection of the anteromedial tibial face. Dissection through the skin and subcutaneous tissues should proceed sharply with maintenance of full thickness skin flaps. Close the ilio-tibial band and if necessary reattach the Gerdy’s tubercle. Keyword: Osteosynthesis, Anterolateral Approach, Distal Tibia References 1.Canale ST, Beaty JH. If necessary release the ilio-tibial tract by incising it or taking a small flake of bone from Gerdy’s tubercle. The transverse branch of the incision is almost in line with the medial incision for talus neck fracture [ 23 ], while the vertical branch is medial to the Achilles tendon and extends proximally based on metaphyseal involvement. The posterolateral approach is an extremely useful exposure to access and manipulate the posterior aspect of the tibial plafond.17, 18 It is most useful for those B-type tibial pilon fractures where the unstable articular segment is located posteriorly and has no significant articular comminution. This approach is typically utilized for split-depression lateral plateau (Schatzker type II) and bicondylar (Schatzker type VI, type V) fracture patterns. The outcome of the patients was assessed after a short to medium follow-up period. Distally, the extensor retinaculum is incised, and the anterior compartment tendons are all retracted medially. This surgical incision can be used for simply split lateral tibial fractures with or without compression and also for comminuted bicondylar tibial fractures. - Posterolateral approach for tibial pilon fractures: a report of two cases - A surgical approach to posterior pilon fractures - Surgical fixation of pilon injuries: a comparison of the anterolateral and posterolateral approach. Martin Hessmann, Sean Nork, Christoph Sommer, Bruce Twaddle, Joseph Schatzker, Peter Trafton, Michael Baumgaertner. Joseph Schatzker, Ernst Raaymakers, Rick Buckley. Contraindications include anteromedial or medial exit of the primary fracture line and primarily medial defects and/or comminution. If this approach is used in a staged fashion, when the soft envelope is ready, it affords excellent visualization for … Plating on the lateral surface of tibial plafond is a new entity and the anterolateral approach is gaining popularity for the fixation of tibial pilon fractures. EPIDEMIOLOGY Avg. OBJECTIVE: The anterolateral approach to the tibia has been popularized for the management of tibial pilon fractures. Many fractures of the tibial plateau can be treated with an anterolateral approach to the proximal tibia. the anterolateral approach to deal with a tibial plateau fracture (Schatzker III) in detail. 34.9 ) is useful in the majority of complete articular (type 43C) pilon fractures, anterior and anterolateral partial articular (type 43B) pilon fractures, and some extra-articular distal tibial fractures that can be stabilized with a plate slid beneath the anterior compartment ( Fig. This video reviews the indications, surgical approach, and case examples of the anterolateral approach to a distal tibial plafond fracture. Radiographs including the foot, ankle, tibia, and knee should be obtained. The threaded rod of the small distractor is placed posterolaterally to avoid interference with reduction and implant placement. This allows exposure of the talar neck for pin placement and distractor application. 2008;22:299–305. A tibial plateau fracture in a 40-year-old male with extensive florid psoriasis. Open the deep fascia anterior to the ilio-tibial tract. anterolateral epiphyseal fracture that is similar to the lateral tibial avulsion fractures observed in cadavers by the late French sur-geon Paul Jules Tillaux in 1892. Treatment of AO/OTA Type C Pilon Fractures Through the Anterolateral Approach Combined With the Medial MIPO Technique Gi Beom Kim, MD , Oog-Jin Shon, MD , and Chul Hyun Park, MD Foot & Ankle International 2018 39 : 4 , 426-432 A prospective study evaluating incision placement and wound healing for tibial plafond fractures. age 35-40 Rare in children Males 3 x more common 3-9% of all tibia fractures Associated injuries 25-50% 6. At the time of closure re-attachment of the meniscus and capsule is mandatory. Opening the fascia. A portion of the posterior tibial tendon sheath is incised to allow displacement of the tendon. Introduction Surgical Technique Product Information Table of Contents 3.5 mm LCP Anterolateral Distal Tibia Plates 2 AO Principles 4 Indications 5 Clinical Cases 6 Preparation 8 Approach 10 Reduce Fracture/Articular Surface 10 This video reviews the indications, surgical approach, and case examples of the anterolateral approach to a distal tibial plafond fracture. DOI: 10.1097/BOT.0b013e3181e5e17d Corpus ID: 205491525. Proximally, the dissection is limited by the origin of the anterior compartment muscles from the fibula and from the interosseous membrane. Do not close the fascia to avoid a compartment syndrome. Due to this reason, the anterolateral approach is the most frequently used surgical approach for tibial plateau fractures. Positioning. Conclusion: Anterolateral plating in the distal end tibial fractures using the anterolateral approach is safe, easy, and effective and has fair the functional outcome with less complication. Approach to Osteochondral Lesions of the Tibial Plafond. Between 2010 and 2011, ten patients with posterolateral tibial plateau fracture were treated using an extended anterolateral approach with a proximal tibial locking compression plate. Material and methods. It is well suited for an accurate articular reduction, as well as submuscular and subcutaneous plate applications spanning metaphyseal comminution. Supine on a radiolucent table. Anterolateral Approach Because most tibial plateau fractures involve thelateral tibial plateau, an anterolateral approach is the most frequently used approach for the treatment of plateau fractures ( Figs. Tibial Plafond Issues Complex / High energy injuries Management of soft tissues critical - restore length with external fixation - await swelling to dissipate Restoration of alignment / Joint surface imperative Outcome guarded - can This portion of the fracture is cleansed and the entrapped periosteum is excised. It may be indicated in anterior and anterolateral AO Type B fractures, in AO Type C fractures with articular damage laterally, and in those cases with a valgus deformity thus requiring a lateral buttress plate. Medial plating using LCP on the subcutaneous medial border of distal tibia resulted in a significant rate of wound dehiscence and deep infection. This video illustrates the indications, surgical approach, case examples and outcomes from pilon fixation through an anterolateral approach. Ch. These muscles and tendons are usually easy to mobilize from the underlying anterior tibiofibular ligament, the periosteum of the distal tibia, and the joint capsule. For complex fracture patterns a combined anterolateral/anteromedial approach is suitable but a high rate of complication has been reported. However, access to the medial ankle joint is poor, and proximal extension is limited. SOFT TISSUE Paucity of soft tissue coverag eon the anterior aspect 5. This surgical incision can be used We present a case of 69 year-old female with a isolated joint-depression fracture of the lateral tibial plateau. Additionally, the distractor helps to align several of the major articular fragments. Bring patient to the foot end of the table. The transverse branch of the incision is almost in line with the medial incision for talus neck fracture [ 23 ], while the vertical branch is medial to the Achilles tendon and extends proximally based on metaphyseal involvement. The patient was managed surgically through a combined angiosome- or perforator-sparing anterolateral approach and a posteromedial approach on day 2 postinjury. It is well suited for an accurate articular reduction, as well as submuscular and subcutaneous plate … Tibial plafond fractures are one of the most challenging injuries in orthopaedic surgery. (From Howard JL, Agel J, Barei DP, et al. Lateral tibial plateau fractures are very common. 2015 Nov;7(4):368-70. doi: 10.1111/os.12205. The diagnosis of a displaced fracture of the tibial plafond is made on these radiographs. - frx of the anterolateral portion of tibial plafond is visualized; - screw placement or pin placement is allowed to cross the physis since the physis is in the process of closing; - … Often there is significant soft tissue injury with a tibial plafond fracture. Illustration shows a partial articular distal tibia fracture. We present our technique for this approach with special focus on performing a submeniscal arthrotomy, placing a femoral distractor and elevation of the joint surface. In order to achieve a successful outcome and minimize the risk of complications, the key point is to master the surgical techniques in detail, and protect soft tissue, following the concept of … Release the proximal attachment of the tibialis anterior muscle. This incision is centered at the ankle joint, parallel to the fourth metatarsal distally, and parallel to and between the tibia and fibula proximally. 2. Campbell's Operative Orthopaedics. The anterolateral approach offers excellent visualization of the tibial articular surface as far as the medial malleolus, while avoiding dissection of the anteromedial tibial face. If this approach is used in a staged fashion, when the soft envelope is ready, it affords excellent visualization for fracture fixation through thick skin flaps. pattern. 11th ed., Vol. Place small bump under the ipsilateral hip and torso. Imaging. Plating on the lateral surface of tibial plafond is a new entity and the anterolateral approach is gaining popularity for the fixation of tibial pilon Anterolateral Approach for Tibial Pilon Fractures David J. Hak, MD, MBA H igh-energy tibial pilon fractures present signifi - cant challenges. 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