What is the step-by-step procedure for treating a proximal tibia fracture using plating?

Step-by-Step Procedure for Proximal Tibia Fracture Plating

The optimal surgical approach for proximal tibia fractures involves percutaneous locked plating (PLP), which shows promising results with minimal complications while achieving functional, pain-free outcomes. 1

Preoperative Planning

• Obtain complete radiographic assessment:

  • AP and lateral views of the tibia
  • CT scan for complex fracture patterns to understand fracture morphology
  • Assess for articular involvement, comminution, and displacement

• Patient positioning:

  • Supine position on a radiolucent table
  • Place a bolster under the affected knee for slight flexion (30°)
  • Prepare and drape the entire limb to allow for intraoperative manipulation

Surgical Approach

For Standard Lateral Plating:

1. Incision and Exposure:

   • Make a lateral incision along the proximal tibia
   • Develop a submuscular plane without stripping periosteum
   • Create an epiperiosteal tunnel for plate insertion

2. Fracture Reduction:

   • Perform closed reduction under fluoroscopic guidance
   • Use temporary K-wires or reduction clamps as needed
   • Restore limb alignment, focusing on equal limb lengths and proper rotational profile 2

3. Plate Application:

   • Insert an appropriately sized locking plate through the submuscular tunnel
   • Position the plate 1-2 cm distal to the joint line
   • Secure with initial proximal and distal screws
   • Confirm plate position with fluoroscopy

4. Fixation:

   • Place locking screws in the proximal fragment (minimum 3-4 screws)
   • Insert screws in the distal fragment (minimum 3 screws)
   • Verify final reduction and hardware position with fluoroscopy

For Complex Bicondylar Fractures:

1. Dual Incision Approach:

   • Anterolateral approach for lateral plateau
   • Posteromedial approach for medial plateau
   • Consider triple plating for complex fractures with biplaner medial plateau involvement 3

2. Fracture Reduction:

   • Reduce articular surface first
   • Restore metaphyseal alignment
   • Use temporary K-wires to maintain reduction

3. Plate Application:

   • Apply lateral buttress plate first
   • Apply medial buttress plate if needed
   • Consider posterior plate for coronal plane fractures

Technical Pearls

• Use fluoroscopy throughout the procedure to ensure proper alignment
• Maintain at least 5mm distance between screws and fracture line
• Ensure screws do not penetrate the articular surface
• Consider using a femoral distractor to aid in reduction
• Avoid excessive soft tissue stripping to preserve blood supply

Postoperative Management

1. Immediate Postoperative Care:

   • Apply sterile dressing and splint/brace
   • Elevate limb to reduce swelling
   • Administer appropriate pain management

2. Rehabilitation Protocol:

   • Begin early range of motion exercises (within 1-2 weeks)
   • Progress to partial weight-bearing at 6-8 weeks based on radiographic healing
   • Full weight-bearing typically by 12-16 weeks

3. Follow-up Schedule:

   • First follow-up at 2 weeks for wound check
   • Subsequent follow-ups at 6 weeks, 3 months, 6 months, and 1 year
   • Radiographic evaluation at each follow-up to assess healing

Expected Outcomes

• Average time to union: 20 weeks for closed fractures, 25 weeks for open fractures 1
• Expected knee range of motion: approximately 119° 1
• Lower extremity functional score: average 59 (74%) 1

Potential Complications and Management

• Infection: Occurs in approximately 8% of cases 1

  • Treat with debridement, antibiotic beads, and prolonged antibiotic therapy

• Nonunion: Rare with proper technique

  • May require cancellous bone grafting if it occurs

• Malunion: Occurs in approximately 20% of cases 1

  • Careful intraoperative alignment is crucial to prevent this complication

• Hardware irritation:

  • May require plate removal after fracture healing

Advantages of Percutaneous Plating

Percutaneous locked plating offers several advantages over other fixation methods:

1. Minimally invasive approach preserves soft tissue and blood supply
2. Rigid fixation prevents secondary fracture collapse
3. Lower infection rates compared to open plating
4. Earlier functional recovery 1

The Less Invasive Skeletal Stabilization (LISS) system has shown excellent results for complex proximal tibia fractures, with satisfactory alignment maintained in 97% of cases and minimal infectious complications 4.