Older man with left ankle pain after a low-speed fall off a motorcycle
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A 75-year-old man presented to the ED with left ankle pain after a low-speed fall off a motorcycle that resulted in a twisting injury to his left leg.
The patient was able to drive his motorcycle following the incident but could not ambulate or weight-bear on his left lower extremity. He reported baseline numbness to his bilateral lower extremities secondary to diabetic peripheral neuropathy.
Source: Filippo F. Romanelli, DO, MBA
The patient’s past medical history included hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, rheumatoid arthritis and gout. His surgical history included three coronary artery bypass grafts, an aortic repair and bilateral total knee arthroplasty. His left TKA was performed in 2002 and was complicated by periprosthetic joint infection (PJI) in 2003, which was eradicated successfully with debridement, antibiotics and implant retention treatment.
On examination, the left leg was moderately swollen with no ecchymosis or open wounds. The patient was tender to palpation over his distal tibia and ankle but was neurovascularly intact. He had a well-healed surgical incision over his knee with no signs of infection. Examination of his left knee showed limited active range of motion (ROM) from 0° to 45°. The patient reported this as his baseline for the past 15 years, along with some varus/valgus instability.
Radiologic evaluation demonstrated a distal-third spiral tibial shaft fracture with an associated distal fibula fracture below a TKA prosthesis. CT scan of the left knee and ankle after immobilization showed a non-displaced posterior malleolar fracture (Figure 1). Prior to his injury, erythrocyte sedimentation rate and C-reactive protein were obtained recently in an outpatient setting and were within normal limits.
What are the best next steps in management of this patient?
See answer below.
Intramedullary tibia nailing after TKA using a modified Tornetta semi-extended approach
Open reduction with plate and screw fixation was considered to avoid the TKA prosthesis entirely, especially in the setting of radiographic evidence of tibial component subsidence, possible PJI and likely need for revision TKA.
However, after careful review of the patient’s knee CT scan, bone quality, past medical history and inflammatory lab results, along with a negative PJI workup 6 months prior, the decision was made to proceed with tibial nailing in a semi-extended position using a lateral parapatellar arthrotomy given the patient’s limited knee ROM.
Careful preoperative measurement of a knee CT scan is essential to ensure there is adequate bone stock in the axial and sagittal planes to accommodate safe tibial nail passage at the stricture points of the tibial baseplate and keel (Figure 2). As shown, the tibial keel is centered just medial to the tibial tubercle on the axial view (19-mm space) and just posterior enough from the anterior cortex on the sagittal view to allow for tibia nail entry (13-mm space).
Details of surgery
The patient was positioned supine on a radiolucent OR table. The fibula was addressed first with a lateral distal fibula approach. Incision was taken down to the peroneal fascia. The superficial peroneal nerve was identified and mobilized anteriorly. The muscle belly was swept posteriorly. The fracture was identified, and length was restored using a lobster retractor clamp to pull traction distally and it was held in place with a 1.6-mm K-wire through the distal fibula into the talus. Clamp-assisted provisional reduction was obtained and held manually with a custom-contoured one-third tubular plate. Locking screws were placed distally and, once appropriate length was confirmed, hybrid fixation was placed with cortical screws proximally above the fracture site in bridging fashion. Fluoroscopic imaging confirmed appropriate length, alignment and rotation of the fibula.
Attention was then turned toward the tibia. A separate incision to the previous arthroplasty incision was made lateral to the patellar tendon from mid-patella to the tibial tubercle with a three-fingerbreadth skin bridge between incisions. A limited lateral parapatellar arthrotomy was performed. Significant scar tissue, which was sent for culture, was encountered and excised at the level of the knee joint to expose the starting point. Gross testing of the TKA polyethylene and tibial baseplate showed stability. The starting guidewire was placed in the appropriate predetermined position on CT and confirmed on orthogonal radiographic views. A soft tissue protector and 11.5-mm opening reamer were used under fluoroscopy to ream the nail entry site. Distal tibia percutaneous stab incisions were made for a large, pointed reduction clamp to obtain and maintain the tibial shaft reduction. A ball-tip guidewire was placed in the appropriate position distally with the aid of a distal medial blocking drill bit to avoid valgus malalignment. The tibial nail length was then measured, and the tibia was sequentially reamed to 11.5 mm. A T2 Alpha (Stryker) 10-mm x 375-mm nail was placed and slightly countersunk to avoid prominence. Fluoroscopic imaging confirmed appropriate length, alignment, rotation and implant placement with the blocking drill bit still maintained (Figure 3). Two proximal locking screws were placed medial to lateral through the jig. The fracture site was compressed by slight impaction and three distal locking screws were placed using the perfect circle technique. The drill bit was removed confirming no movement or malreduction at the fracture site. Next, the posterior malleolus was addressed using a 4-mm cannulated screw placed from anterior to posterior in an appropriate position confirmed on orthogonal views. Stress examination of the ankle noted no syndesmotic or deltoid instability. Examination of the knee noted a stable exam, mild instability in varus unchanged from preoperatively with improvement of ROM with scar excision.
Postoperative radiographs confirmed appropriate length, alignment and rotation of the tibia (Figure 4). The patient was kept non-weight-bearing for 6 weeks given his posterior malleolus fixation.
Discussion
Periprosthetic fractures of the tibia distal to a TKA are rare with an incidence between 0.4% and 1.7% and pose a unique treatment challenge for many surgeons. Risk factors that predispose patients to fracture include component instability and malalignment. Accurate diagnosis based on fracture classification, bone stock availability, implant stability, as well as a clinical workup for infection, are vital to facilitate appropriate treatment.
The Felix and associates classification system, first described in 1997, is used to guide management of tibial periprosthetic fractures and classifies them based on location, as well as proximity to the tibial prosthesis. A stable prosthesis but with displaced diaphyseal fractures has traditionally been treated by open reduction and internal fixation (ORIF) with plate osteosynthesis or external fixation. When fractures are associated with implant loosening, revision arthroplasty may be indicated depending on the location of the fracture and stability of the implant. While our patient had a tibial shaft fracture (Felix type 3) and evidence of a loose tibia component, the fracture site was too distal for a revision stemmed component to bypass. Recent trends have suggested that intramedullary (IM) nailing may offer potential benefits for these types of fractures, such as maximal respect of the tenuous soft tissue envelope surrounding the tibia and early weight-bearing. However, optimal treatment remains controversial because IM nailing distal to a well-fixed TKA is technically challenging due to obtaining the appropriate starting point that can be complicated by positioning of the tibial baseplate, cement or inadequate bone stock.
Previous studies have reported that a suprapatellar approach affords greater ease of achieving an appropriate starting point and nail passage while evading damage to the prosthesis or cortical blowout. In patients with restricted ROM, such as the patient presented in this case report (0° to 45°), a suprapatellar approach in a semi-extended position also avoids the necessity to hyperflex the knee joint. Similarly, recent studies have discussed the use of a direct midline incision mitigating deforming forces complicating the starting point.
In our case, we utilized a lateral parapatellar approach to access the optimal starting point as the location of the tibial baseplate provided adequate space to accommodate the nail and instrumentation slightly anterior and lateral to the tibial tray. The lateral parapatellar arthrotomy also allowed excision of scar tissue and increased visualization of the optimal starting point. While a smaller diameter nail, such as one sized 9-mm, has been reported in the literature as the ideal size for these complex cases, the proximal diameter of the nail and opening reamer sizes must be considered (Table). The proximal diameter sizes range from approximately 11 mm to 15 mm and opening reamer sizes must accommodate these dimensions.
This case is unique in that a lateral parapatellar approach in a semi-extended position was utilized for IM nailing of a distal-third tibial shaft fracture below a TKA. The decision to manage our patient with this technique was multifactorial. ORIF with plate fixation was considered; however, our patient has poor bone quality and a history of diabetes mellitus complicated by peripheral neuropathy, which limits his wound healing potential. Using the IM nailing strategy mitigates the wound healing risks and gives the possibility of earlier weight-bearing. Moving forward, we plan to perform a tibial nail removal of hardware with revision arthroplasty to address the patient’s limited ROM and tibial plate subsidence once radiographic union is achieved.
Key points
- Modified Tornetta, semi-extended lateral parapatellar approach is a safe and effective option for nailing a periprosthetic tibia fracture distal to a TKA as it may afford access to the optimal starting point and available bone stock.
- Understanding instrumentation and implant dimensions, as well as obtaining advanced imaging, such as CT scans, to measure bone stock, are crucial for preoperative planning and successful implant passage when addressing periprosthetic tibia fractures.
- IM nailing distal to TKA offers benefits, such as early weight-bearing and proper healing prior to revision TKA.
- References:
- Born CT, et al. J Am Acad Orthop Surg. 2018;doi:10.5435/JAAOS-D-16-00387.
- Devendra A, et al. Indian J Orthop. 2020;doi:10.1007/s43465-020-00142-2.
- Expert Nailing System Titanium Cannulated Tibial Nail Surgical Technique. pp.1-69. Available at: http://synthes.vo.llnwd.net/o16/LLNWMB8/US%20Mobile/Synthes%20North%20America/Product%20Support%20Materials/Technique%20Guides/DSUSTRM10161152%20Rev%20B.pdf. Published 2021. Accessed Aug. 7, 2022.
- Felix NA, et al. Clin Orthop Relat Res. 1997:113-124.
- Haller JM, et al. J Orthop Trauma. 2014;doi:10.1097/BOT.0000000000000096.
- Hanssen AD, et al. Clin Orthop Relat Res. 2000;doi:10.1097/00003086-200011000-00013.
- Konan S, et al. Bone Joint J. 2016;doi:10.1302/0301-620X.98B11.BJJ-2016-0029.R1.
- Phoenix Tibial Nail System Biomet. pp.1-40. Available at: www.zimmerbiomet.com/content/dam/zimmer-biomet/medical-professionals/000-surgical-techniques/trauma/phoenix-tibial-nail-system-featuring-corelock-technology-surgical-technique.pdf. Published 2014. Accessed Aug. 7, 2022.
- Smith & Nephew Meta-Nail Tibial Nail System. pp.1-44. Available at: www.smith-nephew.com/documents/norway/opr.%20teknikk%20meta%20nail%20tibia%207118-1112%200207.pdf. Accessed Aug. 7, 2022.
- T2 Alpha Tibia Nailing System. pp.1-52. Available at: http://az621074.vo.msecnd.net/syk-mobile-content-cdn/global-content-system/SYKGCSDOC-2-47663/2V7GZ2jP9iCUqX0O1XYZkWvBSsh30Q/T2_ST_20.pdf. Published 2019. Accessed Aug. 7, 2022.
- Tornetta P 3rd, et al. Clin Orthop Relat Res. 1996;doi:10.1097/00003086-199607000-00029.
- Woyski D, et al. J Orthop Trauma. 2016;doi:10.1097/BOT.0000000000000656.
- For more information:
- Kyle D. Auger, DO, MHSA, is an orthopedic resident; Nikki A. Doerr, MS, is a research fellow; Filippo F. Romanelli, DO, MBA, is orthopedic chief resident; and Richard S. Yoon, MD, is fellowship director, Orthopaedic Trauma & Adult Reconstruction Fellowship at Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center/Cooperman Barnabas Medical Center – RWJBH, Jersey City, NJ/ Livingston, NJ. Auger’s email: kdauger9@gmail.com. Doerr’s email: nikki.a.doerr@gmail.com. Romanelli’s email: romanelli.filippo@gmail.com. Yoon’s email: yoonrich@gmail.com.
- Edited by Mark E. Cinque, MD, MS, and Filippo F. Romanelli, DO, MBA. Cinque is a chief resident in the department of orthopedic surgery at Stanford. He will pursue a fellowship in sports medicine at The Steadman Clinic/Steadman Philippon Research Institute following residency completion. His interest is in complex knee surgery and multiligament reconstruction. Romanelli is a chief orthopedic resident at Rutgers – Jersey City Medical Center with an interest in adult reconstruction. He will be at New York University for his fellowship. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
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