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Tibial Eminence (Spine) Avulsion Fracture ORIF

Planning

B

Preoperative Plan

1

Radiographic and MRI assessment

  • fracture classification
  • plan for other pathology that may be present

2

Execute surgical walkthrough

  • describe steps of the procedure to the attending prior to the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • standard arthroscopy tower
  • suture shuttling device
  • ACL drill guide

2

Room setup and equipment

  • standard operative table
  • leg holder (optional)

3

Patient positioning

  • supine position
  • a tourniquet can be placed but may not be needed.

Technique

D

Create Arthroscopic Portals

1

Anterolateral portal

  • an 11 blade is used to create the portal at a 45 degree angle into the joint just lateral to the patella tendon and just inferior to the distal pole of the patella
  • insert the blunt trocar at the same angle as incision

2

Anteromedial portal

  • created under direct visualization once the medial compartment is entered
  • use a spinal needle to assess direction and appropriate superior/inferior direction visualizing the entrance from the lateral viewing portal
E

Perform Diagnostic Arthroscopy

1

Visualize

  • suprapatellar pouch
  • patellofemoral surfaces
  • lateral gutter
  • medial gutter
  • medial compartment
  • visualize the medial femoral condyle and follow it while bringing the knee into slight flexion and applying a valgus stress to the knee as you go into the medial compartment
  • the foot will be positioned on your opposite hip for control
  • medial meniscus, medial femoral condyle, and medial tibial plateau
  • once the anteriomedial portal is created, a probe is used to assess the medial meniscus and cartilage
  • intercondylar notch – ACL/PCL
  • use probe to assess the ACL and PCL
  • lateral compartment
  • the surgeon can bring the leg into a figure-4 position or place the operative limb on the surgeon's hip to create a varus stress and flexion to the knee to enter the lateral compartment
  • lateral meniscus, lateral femoral condyle, and lateral tibial plateau
  • a probe is used to assess the lateral meniscus and cartilage
F

Fracture Reduction and Fixation

1

Anatomically reduce the fracture

  • using a probe, the blunt insert for the trochar, and possibly a grasper to assess the fracture site and reduce the fracture.

2

Drill bone tunnels

  • use the ACL guide to drill 2 parallel 2mm bone tunnels. One on each sides of the bony fracture bed
  • one skin incision is made distally for the two bone tunnels to exit out the anterior tibia which will allow the sutures to be tied over the anterior tibial cortex bony bridge.

3

Place sutures in the ACL

  • use a suture shuttling device to pass sutures through the ACL just proximal to the bone fragment

4

Retrieve sutures and tie

  • the sutures are retrieved through the bone tunnels and tension is applied to supply reduction of the bony fragmant
  • the sutures are tied over the anterior cortex bony bridge creating the proper tension on the ACL and reduction of the bone fragment

5

Check stability of reduction and fixation

  • flex and extend the knee gently while checking the stability of the reduction under direct vision
G

Wound Closure

1

Wound closure

  • standard arthroscopic portal closure
  • separate distal incision can be closed in layers

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • check ROM of the knee
  • check neurovascular status
  • identify medical co-morbidities that might impact surgical treatment

2

Screen medical studies to identify and contraindications for surgery

3

Order basic imaging studies

  • triplanar radiographs of the knee

4

Perform operative consent

  • describe complications of surgery including
  • nonunion
  • malunion
  • arthrofibrosis
  • residual laxity
  • implant related complications
  • growth disturbance
  • loss of motion
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • pain control
  • foley out when ambulating
  • check appropriate labs
  • antibiotics
  • prescribe DVT Prophylaxis

2

Appropriate medical management and medical consultation

3

Discharges patient appropriately

  • pain meds
  • wound care
  • prescribe outpatient PT
  • schedule follow up in 2 weeks
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • check range of motion
  • check neurovascular status
  • concomitant and associated orthopaedic injuries
  • differential diagnosis and physical exam tests

2

Interprets basic imaging studies

  • AP
  • lateral

3

Prescribes and manages nonoperative treatment

  • for type I and reducible type II fractures

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • remove sutures/staples
  • check radiograph
  • start early range of motion
  • diagnose and management of early complications
  • postop: ~ 3 month postoperative visit
  • check radiograph
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies

  • MRI, CT , nuclear medicine imaging and advanced radiographs views

2

Appropriately recomends surgical intervention

3

Modifies and adjusts post-operative treatment plan as needed

O

Complex Patient Care

1

Develops unique, complex post-operative management plans

2

Treats

  • infections
  • dislocations
  • neurovascular compromise
 

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