Updated: 10/9/2017

Bicondylar Tibial Plateau ORIF with Lateral Locking Plate

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Cases
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Techniques
2

Preoperative Patient Care

A

Intermediate Evaluation and Management

1

Obtains focused history and performs focused exam

  • document distal neurovascular status
  • concomitant and associated orthopaedic injuries

2

Interpret basic imaging studies

  • triplanar films of the knee
  • AP
  • lateral
  • oblique

3

Prescribes nonoperative management

  • fracture brace
  • long leg cast

4

Make informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • continue physical therapy and range of motion exercises
  • discontinue DVT prophylaxis
  • wound check
  • staples/sutures removed
  • diagnose and management of early complications
  • continue toe partial weight-bearing at for additional for additional 6-9 weeks
  • postop: ~ 3 month postoperative visit
  • repeat radiographs
  • advance to full weightbearing
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
B

Advanced Evaluation and Management

1

Prioritizes the needs of the polytrauma patient

  • works with consulting

2

Complex wound management and debridement

  • understanding need for consultation for flap coverage

3

Capable of treating complications both intraoperatively and post-operatively

  • manages post operative infection
C

Preoperative H & P

1

Performs focused orthopaedic exam

  • check neurovascular status
  • check for compartment syndrome
  • check soft tissues

2

Appropriately orders basic imaging studies

  • order triplanar radiographs of the knee
  • AP
  • lateral
  • oblique

3

Perform operative consent

  • describe complications of surgery including
  • compartment syndrome
  • infection
  • superficial and deep wound problems
  • residual knee joint instability
  • DVT
  • arthrosis
  • loss of motion

Operative Techniques

E

Preoperative Plan

1

Template fracture reductions

  • draw key fragments of fracture and plan for reduction

2

Execute surgical walkthrough

  • resident can describe key steps of the operation verbally to attending prior to beginning of case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • periarticular clamps
  • K wires
  • cancellous or cortical screws
  • locking femoral condylar plate

2

Room setup and equipment

  • radiolucent flat top table
  • c-arm fluoroscopy

3

Patient positioning

  • place patient supine
  • place a sterile bump or triangle under the knee
G

Posteromedial Approach

1

Mark out and make the skin incision

  • start the incision 1 cm posterior to the posteromedial edge of the tibial metaphysis

2

Identify the neurovascular structures

  • identify the saphenous vein and the nerve
H

Deep Dissection

1

Dissect to fracture site

  • expose the pes anserine tendons
  • mobilize these tendons anteriorly or posteriorly

2

Mobilize the gastrocnemius

  • dissect off the medial gastroc from the posteromedial tibia
  • limit subperiosteal dissection to the fracture margins
  • this will aid in the confirmation of the reduction
I

Lateral Approach

1

Identify and mark anatomy

  • identify gerdys tubercle, the tibial crest,patella and fibular head

2

Mark and make the skin incision

  • the incision should begin distally about 2 cm lateral to the tibial crest, curving over the tubercle of gerdy then proceed superiorly over the femoral epicondyle

3

Dissect through fascia

  • dissect through the fascia without detaching the subcutaneous fat from the fascia

4

Split the IT band

  • split the fibers of the IT band longitudinally parallel to the skin incision
  • be careful not to the disrupt the capsule
  • elevate the IT band off of Gerdys tubercle anteriorly and posteriorly
J

Reduction and Provisional Fixation

1

Identify fracture fragments

  • indirectly reduce the metaphyseal fragments with fluoroscopy

2

Perform provisional fixation with K wires

3

Check reduction

  • check reduction with fluoroscopy
K

Final Fixation

1

Apply plate

  • apply a plate laterally to support the lateral split fragments and to support the depressed articular fragments

2

Create a raft effect with proximal screw placement

  • to produce a raft effect, place multiple screws proximally in subchondral bone
  • four screws are optimal for the rafting effect
  • screws should be placed in the following fashion: fully threaded, partially threaded, fully threaded then partially threaded

3

Provide support of the medial fragment

  • support of the medial side can be provided by a lateral plate if the medial fragment is large enough
  • if fixation of the medial fragment cannot be achieved with a lateral locking plate, placement of a medial plate via the posterior approach is performed
  • this is performed with posteromedial buttress fixation

4

Place locking screws

  • these screws provide superior resistance to medial subsidence and are preferred over nonlocking screws for this application
  • if compression is required, nonlocking screws should be placed before the application of locking screws across the fracture line

5

Fill subchondral defect

  • all defects should be grafted with allograft, autograft or bone substitute
  • use a tamp to impact the graft under the inferior surface of the depressed fragment

6

Elevate the fragment to its proper position

7

Check implant placement

  • check placement of implants with fluoroscopy
L

Wound Closure

1

Irrigation, hemostasis, and drain

  • copiously irrigate the wound
  • irrigate until backflow is clear
  • cauterize peripheral bleeding vessels

2

Deep closure

  • use 0-vicryl to close the deep tissue

3

Superficial closure

  • use 3-0 vicryl for subcutaneous tissue
  • use 3-0 nylon for skin

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • pain control
  • prescribe appropriate DVT prophylaxis
  • wound management
  • remove dressings POD2
  • foley out when ambulating
  • check appropriate labs
  • antibiotics

2

Check radiographs in postop

  • check placement of implants

3

Initiate physical therapy on POD 1

  • start CPM machine at 0 to 40 degrees
  • advance 0 to 5 degrees during each PT session

4

Appropriate medical management and medical consultation

5

Discharges patient appropriately

  • pain meds
  • outpatient physical therapy
  • schedule 2 week follow up
R

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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