PREOPERATIVE DIAGNOSIS: Left bicondylar tibial plateau fracture.
POSTOPERATIVE DIAGNOSIS: Left bicondylar tibial plateau fracture.
OPERATION PERFORMED: ORIF of left bicondylar tibial plateau fracture.
SURGEON: John Doe, MD
ESTIMATED BLOOD LOSS: 150 mL.
DRAINS: None.
SPECIMENS: None.
COMPLICATIONS: None.
CONDITION: The patient is stable to recovery.
INDICATIONS FOR OPERATION: The patient is an adult male who was in an accident approximately 2-1/2 weeks ago where he sustained a traumatic injury to his left tibial plateau. The patient had also sustained orthopedic injuries that were previously treated operatively. The patient had a bicondylar left tibial plateau fracture after his fall, and he was placed in a spanning external fixator soon after his injury. The patient’s soft tissues were allowed to heal, and now, the patient is back at approximately the 2-week mark for definitive ORIF of his bicondylar left tibial plateau fracture. The patient has been consented appropriately and understands the risks and benefits of ORIF.
DESCRIPTION OF OPERATION: The patient was brought to the operating room with the external fixator on his left tibial plateau for ORIF. The patient was placed on the operating room table, and general anesthesia was initiated. The patient’s left lower extremity was then prepped and draped in a sterile fashion, including prepping the external fixator. After the leg was draped out, the external fixator bars were removed, pins were left in place, and sterile tourniquet was placed around the left upper thigh. The fracture was bicondylar in nature, and it was felt that it would be best to approach it through an anterior medial incision.
The anterior medial incision was made over the proximal tibia starting just proximal to the knee joint and continuing distally. Dissection was carried down to the level of the fascia overlying the tibia itself as well as the extensor retinaculum. A small arthrotomy was made adjacent to the medial aspect of the patellar tendon, and dissection was carried down medially on to the shaft. There were several pieces of the joint surface that were noticeable once the joint itself was opened. There was a large medial fragment as well as a tibial tubercle fragment and the lateral fragment. There was also a significant amount of central comminution and joint destruction centrally.
At this point, elevator was used along with irrigation, curettes, and rongeurs to clean up and mobilize the medial fragment. This appeared to be the constant fragment, and it was necessary to reduce the rest of the joint itself. The tubercle fragment was displayed superiorly to the medial fragment, and using manipulation on the knee as well as downward pressures, these two pieces were brought into proximal alignment and then pinned with a K-wire. The tibial tubercle fragment and medial fragment were then brought and drilled to the alignment of the lateral aspect and then K-wires were also placed across the joint to provisionally hold this reduction.
After provisional reduction had been undertaken, the joint was assessed. The medial meniscus was visualized at the joint level. During visual assessment and during the assessment, part of the meniscus was cut, and this was then repaired later in the procedure using 0 PDS sutures. C-arm was used to assess the provisional reduction, and following this, plans were made for definitive fixation.
A Synthes proximal tibia periarticular locking plate was chosen. It was an 8-hole plate. The plate was placed along the medial aspect of the tibia in order to have a buttress effect. The plate was applied without difficulty along the medial aspect of the tibia. It was then decided before plate application that stabilizing small fragment screws be placed across the joints from the medial to the lateral fragments. This was done using a 2.5 drill and a standard 3.5 mm fully threaded screw.
Following this, the tibial plate was applied and the three articular locking screws were placed along the proximal aspect of the plate. Two additional locking screws were placed in the proximal aspect of the plate and the proximal fracture fragments. A total of four shaft screws were then placed distally using a small incision over the distal aspect of the plate to find the screws with care to avoid the saphenous nerve and vein. All screws used distally in the shaft were nonlocking 4.5 mm screws. The locking screws proximally were 5.0 mm screws.
Following this, it was decided that additional fixation was needed to secure the tibial tubercle fragment to the medial fragment, and therefore, another 3.5 mm screw was placed from anterior to posterior in order to provide fixation of the tubercle fragment to the medial fragment.
Following this, final fluoroscopic images and plain films were assessed and found to be overall appropriate. Overall alignment of the joint was restored. The wound was then irrigated thoroughly with normal saline. Small percutaneous wounds were made during the case for the placement of reduction and clamps were also irrigated.
Following this, the major incision along the anterior medial and proximal aspect of the tibia was closed using 0 Vicryl to the deep tissues followed by 2-0 Vicryl for the skin and staples for final skin closure. The smaller incision made along the distal aspect of the plate for insertion of distal shaft screws were closed using 2-0 Vicryl in inverted fashion followed by staples for final skin closure. The leg was washed with wet and dry gauze.
Two percutaneous incisions made for placement of reduction forceps, during reduction of the fragments, were each closed with single staple. Following this, standard sterile dressings were place and the wounds were wrapped. After the wounds had been wrapped, the previous pins from the external fixator were removed. Two pins were removed from the tibia and two pins were removed from the femur.
During the case, the external fixator was applied provisionally to help hold our provisional fixation. This was taken down and then the pins were removed. With the surgical wounds closed, each of the four holes was curetted out and irrigated thoroughly, and Adaptic dressings were placed over these previous ex-fix pin sites.
Following this, the leg was wrapped with an Ace wrap, and the patient was placed in a knee immobilizer and then awoken from general anesthesia and transported to recovery in stable condition.
