Name:
Posteromedial Tibial Plateau Fixation
Description:
Posteromedial Tibial Plateau Fixation
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/86734de2-e71a-477c-891a-52b43c7a3b9b/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H09M49S
Embed URL:
https://stream.cadmore.media/player/86734de2-e71a-477c-891a-52b43c7a3b9b
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/86734de2-e71a-477c-891a-52b43c7a3b9b/Posteromedial tibial plateau fixation.mp4?sv=2019-02-02&sr=c&sig=XOp1hxIwywWDteFcNlH12Px%2FpOCdiUXxVHqyWH7dAVk%3D&st=2024-11-21T17%3A41%3A13Z&se=2024-11-21T19%3A46%3A13Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ASHOK GAVASKAR: This is Dr. Ashok Gavaskar and I will be demonstrating the surgical technique video of how to do a postural medial tibial plateau ORIF. There's a young male who had a motor vehicle accident resulting in a bicondylar fracture pattern, you can see a simple postural medial split component and a more complex lateral side. His skin was OK and it was planned for a single stage ORIF.
ASHOK GAVASKAR: CT scan shows the single large posteromedial fracture fragment, extending distally and also a large extent towards the lateral side. You can look at the lateral injury being more complex with a split depression component. The conventional posterial medial exposure was performed with the patient lying supine.
ASHOK GAVASKAR: Skin, superficial tissues are taken down to expose the deep fascia. The deep fascia is incised in line with the skin incision, keeping in mind the underlying test tendons. The hamstring tendons are further mobilized to facilitate exposure and retract them on either side.
ASHOK GAVASKAR: The plane between the medial gastrocnemius and the semi membrane also is developed next. There's the middle gastron being mobilized and as you can go proximially, you can identify the semi endomembrane system and right there. After this,
ASHOK GAVASKAR: the property soleus complex is slowly taken off, sub-periosteally from the proximal posterior tibia. As you go more and more laterally, you got to be cognizant of the femoral neurovascular structures and you have to stay strictly separate or still. This exposes the fracture, as you can see, the fracture lines coming into view.
ASHOK GAVASKAR: The exposure is extended laterally, keeping in mind the LARS lateral extent of this fracture fragment. The fractured plains are further mobilized to facilitate reduction. The limb is brought into extension, the fracture is clamped and held in place by using an asymmetric pelvic clamp.
ASHOK GAVASKAR: You can appreciate fracture reduction and clamp placement here. Once reduced, fixation is performed by using ante-posterior subarticular lag screws. In this case, 3.5 screws are used, two screws are used, placed more towards the midline, keeping in mind the LARS, large lateral extent of this fracture fragment.
ASHOK GAVASKAR: Once screws are inserted, they are strong enough to hold this fracture in place, so that you can slowly bring the limb to flexion to facilitate posteromedial plating. The plate is positioned and once the position is confirmed, a screw is placed just distal to the fracture apex to provide the necessary anti glide effect.
ASHOK GAVASKAR: The screw is measured, and then a 3.5 millimeter cortical screw is placed, pushing the plate towards the fracture to provide the necessary buttress effect. Then see how my image confirms plate placement and good fracture reduction.
ASHOK GAVASKAR: Further screws are placed distally so as to provide rotation stability and also to secure the fracture. And good quality bone locking screws are not necessary. No fixation is normally necessary towards the proximal position of the plate. So this image shows appropriate plate positioning, fracture reduction, and then you can go on to the lateral side.
ASHOK GAVASKAR: Now the postoperative images showing good fracture reduction and healing at six months. This is another case, a 35-year-old male, just to show you the more complex posteromedial injury pattern. This patient had a bicondylar fracture with a lot of swelling, so he was planned for a stage reconstruction with external fixator, after which definitely what can be done.
ASHOK GAVASKAR: There are three articular fragments on the medial side. If you want to reduce the posteromedial condyle, in this case, it is important to re-establish the articular relationship between these fragments and also correct varus. To do that, you might require access to the articular surface to visualize the reduction. This can be done by splitting the medial collateral ligament longitudinally without disturbing it too much. If it is posterior enough then an arthrotomy is much simpler.
ASHOK GAVASKAR: So once articular reduction is achieved, relax screws from anterior to posterior will secure reduction followed by plate application on the medial column to correct varus followed by posteromedial and anteromedial plating to buttress the remaining fragments. We're going the same postural medial approach is performed. You can appreciate the greater extent of soft tissue injury in this case.
ASHOK GAVASKAR: The hamstring tendons are mobilized and the property soleous complex, is mobilized sub-periosteally from the posterior tibia. You can appreciate the displacement between the proximal and distal fragments and also appreciate the completely mobile distal fragment, devoid of any attachment to the proximal fragment.
ASHOK GAVASKAR: The hamstring tendons are tagged for retraction. In this case, the split between the posteromedial fragment and the anterior fragment was posterior to the deep MCL attachments. So a simple arthroscopy was performed, k-wires were placed into those two fragments to act as joysticks to help in reduction.
ASHOK GAVASKAR: You can see k-wire placements into those two fragments in this image. These two fragments are joysticked into place. This can be helped by further mobilization. This is the posteromedial fragment, that is the more anterior fragment. So once they are brought into place and reduced, they are held in place by using an anterior to posterior placed
ASHOK GAVASKAR: k-wire. This, followed by lack of fixation from anterior to posterior. Two screws are placed to facilitate articular reduction. Now a shafts pin from anterior to posterior is placed more distally to correct the sagittal plane deformity and hold reduction in place.
ASHOK GAVASKAR: Once reduction is performed, the first plate that we place is the medial column plate. Screws are placed first in the distal segment to help in correcting coronol alignment and once correction of varus is confirmed, screws are placed into the proximal fragment.
ASHOK GAVASKAR: CR image confirms good correction of varus. Next, we go ahead with the posteromedial plate application. Screw this plate distal to the apex to provide anti glide effect. You can appreciate good fracture reduction and fixation after posteromedial plate fixation.
ASHOK GAVASKAR: Fixation is further completed by adding an anteromedial buttress plate to stabilize the anterior most fragment on the medial side. This is the postoperative X-ray at four months demonstrating good articular reduction alignment and fracture healing. Thank you.
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