From the Guidelines
The treatment of a proximal tibia fracture using plating involves a systematic surgical approach, with the goal of achieving anatomic reduction and stable fixation to minimize morbidity and mortality, as recommended by recent guidelines 1.
Preoperative Planning
The procedure begins with preoperative planning, including radiographs and CT scans to assess the fracture pattern and determine the appropriate plate selection. This step is crucial in ensuring that the correct implant is used and that the surgical approach is well-planned.
Surgical Approach
After administering appropriate anesthesia and prophylactic antibiotics (typically cefazolin 2g IV), the surgeon positions the patient supine with a bump under the affected knee. A tourniquet is applied to the thigh and inflated after limb exsanguination. The surgical approach is typically anterolateral or anteromedial, with careful dissection to expose the fracture while protecting neurovascular structures.
Fracture Reduction and Fixation
Once exposed, the fracture is reduced anatomically using reduction clamps and temporary K-wires. Articular surface restoration is critical, with subchondral screws used to secure articular fragments. A precontoured locking plate is then positioned on the lateral or medial side of the proximal tibia, with locking screws placed proximally to support the articular surface and conventional or locking screws distally to secure the plate to the tibial shaft.
Intraoperative and Postoperative Care
Intraoperative fluoroscopy confirms proper reduction and implant placement. The wound is irrigated, a drain may be placed, and closure is performed in layers. Postoperatively, the limb is immobilized in a hinged knee brace, with early range of motion exercises beginning within 1-2 weeks. Weight-bearing is typically restricted for 10-12 weeks until radiographic evidence of healing. The use of negative pressure wound therapy (NPWT) can be considered for high-risk surgical incisions, as recommended by recent guidelines 1.
Key Considerations
The key to a successful outcome is achieving anatomic reduction and stable fixation, while minimizing the risk of complications such as infection and nerve damage. The use of prophylactic antibiotics and careful surgical technique can help to reduce the risk of infection, as recommended by recent guidelines 1. Additionally, the use of a multidisciplinary approach, including orthoplastic surgery, can help to improve outcomes in complex cases.
- The procedure should be performed by an experienced surgeon, with careful attention to detail and a focus on achieving anatomic reduction and stable fixation.
- The use of locking plates and subchondral screws can help to provide stable fixation and support the articular surface.
- Early range of motion exercises and weight-bearing restriction can help to promote healing and reduce the risk of complications.
- The use of negative pressure wound therapy (NPWT) and multidisciplinary approach can be considered in high-risk cases, as recommended by recent guidelines 1.
From the Research
Step-by-Step Procedure for Treating Fracture of Proximal Tibia by Plating
- Preparation: The patient is prepared for surgery, and the affected limb is cleaned and draped in a sterile manner.
- Incision: A limited open technique is used to make an incision over the proximal tibia, allowing for access to the fracture site 2.
- Reduction: The fracture is reduced, and the alignment is corrected using fluoroscopic guidance.
- Plate fixation: A locked plate is applied to the proximal tibia, spanning the fracture site and providing stability to the bone 3, 4.
- Screw fixation: Screws are inserted into the plate and into the bone on either side of the fracture, securing the plate in place.
- Closure: The incision is closed, and the wound is dressed.
Considerations and Outcomes
- The choice of treatment between plating and intramedullary nailing depends on the fracture pattern and the patient's individual needs 4, 5, 6.
- Plating has been shown to have a lower risk of malunion and postoperative compartment syndrome compared to intramedullary nailing 4.
- However, intramedullary nailing has been associated with a shorter time to union and lower risk of superficial infection 4, 5.
- The outcomes of plating and intramedullary nailing have been compared in several studies, with mixed results 4, 5, 6.
- A multicenter randomized controlled trial found no significant difference in outcomes between locked plating and intramedullary nailing for proximal tibia fractures 6.
Potential Complications
- Malunion: The bone may heal in an incorrect position, leading to deformity and functional impairment 4.
- Nonunion: The bone may fail to heal, leading to ongoing pain and instability 4, 5.
- Infection: The surgical site may become infected, leading to further complications and potentially requiring additional treatment 4, 5.
- Compartment syndrome: The muscles and nerves in the affected limb may become compressed, leading to pain, numbness, and weakness 4.