What is the approach for medial tibia plate removal?

Approach for Medial Tibia Plate Removal

The optimal approach for medial tibia plate removal involves a careful surgical technique along the previous incision site with minimal soft tissue dissection to reduce complications and optimize functional outcomes.

Preoperative Assessment

• Confirm radiographic evidence of bone healing before plate removal
• Evaluate for any signs of infection or hardware complications
• Review original operative report to understand plate position and fixation details
• Assess patient's symptoms related to hardware (pain, irritation, prominence)
• Consider timing of removal (typically 12-18 months after initial surgery if symptomatic)

Surgical Technique

Patient Positioning and Setup

• Supine position with a bump under the ipsilateral hip for optimal access
• Tourniquet application at mid-thigh level
• Sterile preparation and draping of the entire limb

Incision and Approach

1. Utilize the previous surgical incision along the medial aspect of the tibia
2. Make a careful subcutaneous dissection directly to the plate
3. Protect the saphenous vein and nerve during the approach
4. Elevate the periosteum only as needed to access screws and plate

Hardware Removal Sequence

1. Remove all screws first, starting from either end of the plate
2. If screws are difficult to remove due to bony overgrowth, carefully clear the screw heads
3. Once all screws are removed, gently elevate the plate from the bone surface
4. Avoid excessive force that might cause iatrogenic fracture

Wound Closure

1. Irrigate the wound thoroughly
2. Close the deep fascia with absorbable sutures
3. Close subcutaneous tissue and skin in layers
4. Apply sterile dressing and light compression bandage

Postoperative Management

• Weight-bearing as tolerated immediately after surgery in most cases
• Early range of motion exercises to prevent stiffness
• Consider protected weight-bearing for 2-4 weeks in cases with large screw holes or concerns about bone integrity
• Follow-up radiographs at 2-4 weeks to confirm absence of complications

Potential Complications and Management

• Refracture: Most common after plate removal from load-bearing bones. Consider protected weight-bearing in high-risk cases 1
• Wound complications: Careful soft tissue handling and tension-free closure can minimize this risk 2
• Retained hardware fragments: Ensure complete removal of all hardware components
• Neurovascular injury: Careful identification and protection of the saphenous nerve and vein during the approach

Special Considerations

• In cases where the plate has significant bony overgrowth, limited exposure of the plate edges may be necessary
• For plates used in high tibial osteotomy, removal rates are high (52%) due to hardware prominence 3
• Minimally invasive approaches should be maintained during removal to preserve soft tissue integrity 4, 5
• Consider prophylactic antibiotics for the procedure, especially in patients with previous infection history

Timing of Plate Removal

• Symptomatic hardware is the primary indication for removal
• Younger patients are more likely to undergo hardware removal (10.9 vs. 13.2 years, p=0.04) 1
• Consider patient's activity level and functional demands when deciding on removal timing
• Ensure complete bone healing before plate removal to prevent complications

This approach balances the need for adequate exposure with minimal soft tissue disruption, optimizing outcomes while reducing the risk of complications following medial tibial plate removal.