tibial plateau pre-webinar cases

• Non-op
• Percutaneous screw fixation +/- CaPO4 augmentation
• ORIF with lateral plate
• Acute TKA

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• NWB 6 weeks
• NWB >6 weeks
• PWB 6 weeks
• PWB >6 weeks
• Unrestricted
• Other

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• Non-op
• Percutaneous screw fixation +/- CaPO4 augmentation
• ORIF with lateral plate
• Acute TKA

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• NWB 6 weeks
• NWB >6 weeks
• PWB 6 weeks
• PWB >6 weeks
• Unrestricted
• Other

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• Bicondylar fractures
• Depressed fractures
• Pre-existing knee OA
• Poor bone quality
• Bilateral fractures
• It is never indicated

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• Standard primary tibial baseplate
• Tibial stem
• Bone graft and stemmed tibia
• Augment and stemmed tibia
• Cone and long stem
• Asymmetric cone and stem
• Sleeve and stem

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• Absolutely, yes. Go non-op and allow it to heal up in a hinged knee brace, if he’ll wear it. TKR is the salvage if it doesn’t work out.
• Examine in ED or in Clinic, possibly with some LA in the knee. If clinically valgus unstable, then orif. Otherwise, non-op
• I’d go for MUA and if unstable, go for ORIF; but if not radiologically displacing on valgus stress then hinged knee brace
• That absolutely needs orif, otherwise he’s going to come back collapsing into the healed defect. At which point, he’ll still be alcoholic and non-compliant, but now with an unstable knee!
• This needs internal fixation for sure, but I would go for a circular frame, rather than orif.

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• I like to go for an ex-fix in the short term until the soft tissues are right down
• No need for ex-fix but I would put in plaster or brace until swelling is down
• Swelling my ass! I would crack-on with orif at the next available list
• I usually wait 2-3 days to let things settle down before fixing
• I’m using a circular frame, so timing is not an issue - go whenever.

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• It’s going to have a lovely circular frame, with the rings and connectors beautifully obscuring the reduced joint line!
• There will just be 2-3 screws compressing the joint from lat-to-med.
• Lateral plate but entirely non-locking, in buttress mode
• Lateral plate in locking mode
• Lateral plate in some kind of hybrid mode (combination of L and N-L)

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• In older pts, I’m more likely to go with non-op treatment for less displaced fractures since they are lower demand and the consequences of minor mal-union are less.
• This lady’s knee is totally screwed and she’s likely to end up with a TKR. So I would leave alone, pending arthroplasty down the line
• Older patients need to mobilise rapidly and they may struggle with a brace, so I’m just as likely to fix as in younger pts
• If anything I’m more more likely to fix a plateau fracture in an older patient (assuming they’re well enough), since they wont be able to tolerate non-op treatment (brace and limited wt bearing)

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• When fixing fractures like this, my metalwork construct is the same, as for a younger patient
• I tend to be more minimal for older patients - maybe just some screws to compress the joint
• I tend to be more aggressive with older patients, in terms of the amount of metalwork, plates screws etc
• Older patients lend themselves more to a circular frame construct, so that’s my preference.
• I’m going for TKR as my definitive surgery here, either right away or after the fracture is healed.

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• I love squirting in a bit of bone substitute at the end of surgery. I feel it adds to the stability of the construct, particularly in older patients. Plus, if you can antibiotics too!
• As above but, in particular, I’m more a fan of (Ca)xPO4
• As above but I’m more a fan of CaSO4
• I’m not a massive fan of bone subs but if there is a very large void at the end of fixation and I’m worried about my fixation, I might supplement with some white calcium juice. I’m an occasional user
• OMG, these substitutes are totally pointless, non-evidence-based and they create more problems than they solve, whilst also adding unjustifiable expense the the surgery. Not a fan

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• Older patients can’t hop! Even this otherwise healthy 72 yr old. Therefore, I would mobilise wt bearing as tolerated in a brace post-op
• I allow pts to stand and move about the bed-space freely in brace but avoid walking more than a few yards to minimise the effect on the fracture fixation.
• I ask the therapists to try to limit wt bearing on the affected side for 4-8 weeks, accepting that this will restrict their mobility a bit and the pt may not be totally compliant.
• 4-8 wks NWB, otherwise the whole thing will squish down, making the operation pointless! They can still get out of bed and sit on commode etc, it’s only for a few weeks! They have to just suck it up

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• I’m going prone with a posterior approach right through the middle, lazy-S style
• I’m going prone but doing a postero-medial approach behind med. head of gastroc.
• I’m going supine, maybe with figure-4 to get further back.
• I like to go lateral position, bad side down. This gives really nice access to the back of the tibia
• I’m going lateral position, bad side up, to address the posterolateral depression AND the posteromedial fracture through one approach
• None of the above. I like to hang the leg off the end of the operating table, giving me 360 degree access to do whatever approach I like. Probably start posteromedial.

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• This doesn’t need fixing. Once the medial side is sorted, the lateral will reduce and will not be a source of instability.
• I’m already prone, so I’d try to address this through my posterior approach
• Getting across to the very lateral part of the prox tibia is tough, even when prone. So I’d do a separate approach anterolateral, punch up the fragment and fix in the usual way that I’d fix any plate
• This is perfect for a posterolateral approach, dissecting out the CPN any possibly cutting the fibular to move it out of the way.

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• Poor cosmesis of the scar
• Fixed flexion deformity
• Wound breakdown and delayed healing
• Iatrogenic neurological deficit
• Post-traumatic arthritis
• Knee instability (ACL avulsed)

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