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Minimally invasive posteromedial percutaneous plate osteosynthesis for diaphyseal tibial fractures: technique description
S6 Injury, Int. J. Care Injured 48S4 (2017) S6–S9 Volume 48 Issue 6 June 2017 ISSN 0020-1383
Contents lists available at ScienceDirect
Injury j o u r n a l h o m e p a g e : w w w. e l s e v i e r . c o m / l o c a t e / i n j u r y
Minimally invasive posteromedial percutaneous plate osteosynthesis for diaphyseal tibial fractures: technique description Andre Wajnsztejna,*, Robinson Esteves Santos Piresb, Alexandre Leme Godoy dos Santosc, Pedro Jose Labronicid, Helio Jorge Alvachian Fernandese, Mario Ferrettia a
Hospital Israelita Albert Einstein, São Paulo (SP), Brazil Universidade Federal de Minas Gerais, Belo Horizonte (MG), Brazil c Universidade de Sao Paulo, São Paulo (SP), Brazil d Universidade Federal Fluminense (UFF), Niterói (RJ), Brazil e Universidade Federal de São Paulo, São Paulo (SP), Brazil b
K E Y W O R D S
A B S T R A C T
Tibial fractures Fracture fixation Anatomy MIPO
Purpose: The aim of this study was to evaluate the feasibility of performing minimally-invasive plate osteosynthesis (MIPO) in tibial fractures using two posteromedial incisions, and to measure the distance between the plate and neurovascular structures. Materials and methods: We performed nine dissections of specimens that were submitted to tibial MIPO with two posteromedial incisions. One locking compression plate (LCP) of 14 to 16 holes was inserted into the submuscular tunnel in a retrograde manner. Incisions were linked to evaluate the distance between neurovascular structures and the plate. Results: During the proximal incision, a blunt dissection between semitendinosus and medial gastrocnemius tendons, as well as their lateral shift, helped to protect the main local neurovascular structures. In its distal portion, the submuscular plate tunnel insertion and its direction to the proximal incision prevented direct contact and possible damage to neurovascular structures. Moreover, we obtained successful results from a patient submitted to this procedure. Conclusion: Posteromedial MIPO represents a safe and attractive alternative for tibial fractures, particularly if there are damaged soft tissues in the anterior and medial side, or when access to intramedullary osteosynthesis is blocked. © 2017 Elsevier Ltd. All rights reserved.
Introduction
To perform MIPO in the posterior side of the tibia, we combined two techniques: the Lobenhoffer approach for treatment of tibial plateau fractures and the Assal modified tibial pilon posteromedial approach [9,10]. Both techniques are safe, with a low rate of complications. The aim of this study was to evaluate the feasibility of performing MIPO in tibial fractures using two posteromedial incisions, and to measure the distance between the plate and neurovascular structures. This technique can be a treatment option for selected cases, like patients with poor anterior and medial soft tissue condition, peri-implants and periprosthetic fractures, and adolescents with open physis.
Tibial fractures are the most common lesions of long bones. Data from the National Center for Health Statistics indicate an annual prevalence of 492,000 tibial fractures per year in the United States [1]. Open fractures usually occur as a result of high-energy trauma and closed fractures are related to falls and sports accidents. Tibial diaphyseal fractures represent more than 70,000 hospitalisations per year and 800,000 office visits per year in the United States [2–4]. Tibial fractures are usually associated with soft tissues injuries, particularly in the anterior and medial side [5]. Moreover, incision breakdown, skin necrosis and infections are possible outcomes in such fractures [6]. Interlocking intramedullary nail (IMN) and minimally invasive plate osteosynthesis (MIPO) on anterior or medial sides of the tibia are the most common treatment options for diaphyseal tibial fractures [7]. Staged treatment with temporary external fixators can be used until soft tissue conditions are suitable for internal fixation [8]. * Corresponding author. E-mail address: [email protected] (A. Wajnsztejn). 0020-1383/© 2017 Elsevier Ltd. All rights reserved.
Materials and methods Anatomical aspects After approval by the Ethics Committee in Research from the institution, nine legs from five fresh cadavers were dissected. All procedures were realised in ventral decubitus.
A. Wajnsztejn et al. / Injury, Int. J. Care Injured 48S4 (2017) S6–S9
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Fig. 2. Posterior view of right leg. Exposure of the Tibial nerve (Tn) on the deep posterior compartment of the leg. Flexor Hallucis Longus (FHL) should be retracted laterally.
Fig. 1. Posterior view of right leg depicting the dissection of the proximal medial approach. Dissection between Medial Gastrocnemius muscle (GTm) and Pes anserinus tendons (Pat).
Proximal approach This surgical technique was developed using the incision described by Galla and Lobenhoffer for the treatment of posteromedial tibial plateau shear fractures [9,11]. Thus, we used as a reference the medial gastrocnemius muscle (GTm) head and the pes anserinus tendons. An 8-cm longitudinal incision at the GTm head was performed, distal to the popliteal fold. After dissecting the subcutaneous tissue, we dissected the fascia in the same direction. Superficial structures between the gastrocnemius heads, such as the small saphenous vein (SSv) and the sural nerve (Sn), were not approached. The dissection was continued medially to the GTm at the interval of semitendinosus tissue (Fig. 1). In a deeper layer, popliteal and soleus muscles were elevated from the bone to enable insertion of the implant. In this deeper dissection, the popliteal artery (Pa) is located between GTm heads. It is divided in the anterior and posterior tibial arteries (ATa and PTa, respectively). The ATa penetrates the posterolateral portion of the interosseous membrane at 46 mm from the joint [12]. As the head of GTm is shifted laterally, the muscle protects all these structures, without any contact with the implant. The tibial nerve (Tn) is a neural structure that remains close to the synthesis material. The plate is inserted underneath the flexor digitorum longus (FDL) and posterior tibial (PT) muscles, protecting the Tn. Also, the posterior tibial vein (PTv) and PTa remain laterally located to the Tn. Distal approach The references for the distal approach are the Achilles tendon and the medial malleolus. The incision starts 1 cm medially to the Achilles tendon and at 8 cm proximally to its insertion, for an
extension of 5 cm. After opening the superficial fascia, the Achilles tendon is shifted to the lateral side. The intermuscular septum that divides superficial and deep compartments is sectioned. We then identify the Tn and the muscular portion of the flexor hallucis longus (FHL) (Fig. 2). An interval between FHL and Tn is developed, exposing the metaphyseal region of the bone, leaving the PTa, the PTv and the Tn protected without traction [10]. The FHL is moved laterally. Submuscular incisions are linked using periosteal elevators. A 4.5-mm locking compression plate (LCP; DePuy Synthes) of 14 to 16 holes was inserted in a retrograde manner after previous modelling (Fig. 3). Finally, to secure the procedure, we connected the incisions (Fig. 4). The shortest distances between the plate and these neurovascular structures were measured using a Vernier calliper with precision of 0.01 mm (Starret Co, Ltda São Paulo, Brazil). Results Proximal approach As SSv and Sn are situated at the superficial layer, we measured the distance from these structures to the incision in the skin. The range of distances between the distal portions of the incision to the Sn was 27.54–38.94 mm (mean, 32.60 mm) and to the SSv was 22.33–34.52 mm (mean, 27.08 mm). From the deepest layer, the distance between the Tn and the implant was 6.3–10.2 mm (mean, 7.9 mm). Distal approach Care was taken to open the intermuscular septum: Tn is located just below the incision. The risk of vascular injury was higher than that of neural injury. The shortest distance between the plate and the Tn was 7.8–21.16 mm (mean, 12.7 mm), whereas the distance between the PTa and implants was 7.6–17.4 mm (mean, 10.6 mm), and the distance between the plate and PTv was 8.3–18.1 mm (mean, 11.6 mm).
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A. Wajnsztejn et al. / Injury, Int. J. Care Injured 48S4 (2017) S6–S9
Fig. 3. Posterior view of right leg with a 4.5mm locking compression plate inserted through surgical approaches.
FDL and PT muscle bellies protected neurovascular structures from direct contact with the metallic implant. Discussion There is still no consensus regarding the ideal treatment for shaft and distal tibial fractures [13]. MIPO has been associated with promising results as it permits fracture healing and consolidation with minimal tissue injury or fracture haematoma destruction [14]. MIPO differs from the open reduction method, as the latter promotes more damage to osseous vascularity [15]. Tibial fractures are usually accompanied by soft tissue injuries, which occur in the anterior and medial sides of the leg [8]. On the other hand, the posterior region of the leg has minimal soft tissue injury. Kritsaneephaboon et al. suggested a posterolateral approach for distal tibial fracture osteosynthesis that can be used when anterior soft tissue is compromised [16]. The authors used two posterolateral incisions, at both proximal and distal windows, and the implant site was located in an interval between the FHL and peroneal muscles. The mean distance between the plate and PTa was 4.49 mm. In contrast to the use of two posterolateral incisions suggested by Kritsaneephaboon et al., we advocated two posteromedial incisions for MIPO of tibial fractures. Posterolateral incision is limited by ATa, and cannot be extended proximally. On the other hand, posteromedial incision can be extended proximally to the tibial plateau. Yamamoto et al. published a retrospective case series of posterior tibial MIPO [6]. In their technique, the authors combined a
Fig. 4. Posterior view of right leg after the incisions were connected. Tibial neve (Tn) was marked with a radiopaque thread (*) and distance between the plate and the Tn was measured.
posteromedial distal incision with a posterolateral proximal approach to avoid the anatomical variants in the ATa position. As the plate was inserted in an oblique fashion (inclined), there were anatomical restrictions to increase the stiffness/elasticity of the fixation. We suggest an MIPO technique using two posteromedial windows. We believe that such an approach is easier than the posterolateral approach, as we are able to use longer implants, extending throughout the entire tibial length, possibly leading to alternative surgical options for proximal, diaphyseal and distal tibial fractures. Posteromedial MIPO is not the first choice to treat tibial shaft fractures, but can be a good option for specific cases, such as patients with soft tissue injuries in the anterior and medial sides, or teenagers. Our study has some limitations. We used a small sample of cadaveric specimens, and those specimens did not show any anatomic abnormalities usually seen in fractures. Moreover, the selected implant was bulky and straight and required modelling. Developing specific anatomical implants for such a technique may facilitate the surgical procedure. Therefore, studies with a higher level of evidence and greater sample size are needed to clarify the potential benefits of this surgical technique. Conclusion Taking into account the treatment options for tibial fractures, we consider posteromedial MIPO to be a good alternative technique for selected cases. In vivo studies are necessary to validate this technique.
A. Wajnsztejn et al. / Injury, Int. J. Care Injured 48S4 (2017) S6–S9
Conflict of interest The authors acknowledge that there are no possible conflicts of interest in the manuscript, including financial, consultant, institutional and other relationships that might lead to bias. References [1] Grütter R, Cordey J, Bühler M, Johner R, Regazzoni P. The epidemiology of diaphyseal fractures of the tibia. Injury 2000;31(Suppl 3):C64–7. [2] Clement ND, Beauchamp NJF, Duckworth AD, McQueen MM, Court-Brown CM. The outcome of tibial diaphyseal fractures in the elderly. Bone Joint J 2013;95-B:1255–62. [3] Schmidt AH, Finkemeier CG, Tornetta P. Treatment of closed tibial fractures. Instr Course Lect 2003;52:607–22. [4] Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg Br 1995;77:417–21. [5] Ferguson M, Brand C, Lowe A, Gabbe B, Dowrick A, Hart M, et al. Outcomes of isolated tibial shaft fractures treated at level 1 trauma centres. Injury 2008;39:187–95. [6] Yamamoto N, Ogawa K, Terada C, Okazaki Y, Munetomo K, Noda T, et al. Minimally invasive plate osteosynthesis using posterolateral approach for distal tibial and tibial shaft fractures. Injury 2016;47:1862–6. [7] Vallier HA. Current evidence: plate versus intramedullary nail for fixation of distal tibia fractures in 2016. J Orthop Trauma 2016;30(Suppl 4):S2–S6.
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[8] Lavini F, Dall’Oca C, Mezzari S, Maluta T, Luminari E, Perusi F, et al. Temporary bridging external fixation in distal tibial fracture. Injury 2014;45:S58–S63. [9] Galla M, Lobenhoffer P. Der direkte dorsale Zugangsweg zur Versorgung posteromedialer Luxationsfrakturen des Tibiakopfes. Der Unfallchirurg 2003;106:241–7. [10] Assal M, Ray A, Fasel JH, Stern R. A modified posteromedial approach combined with extensile anterior for the treatment of complex tibial pilon fractures (AO/ OTA 43-C). J Orthop Trauma 2014;28:e138–45. [11] Fakler JK, Ryzewicz M, Hartshorn C, Morgan SJ, Stahel PF, Smith WR. Optimizing the management of Moore type I postero-medial split fracture dislocations of the tibial head: description of the Lobenhoffer approach. J Orthop Trauma 2007;21:330–6. [12] Heidari N, Lidder S, Grechenig W, Tesch NP, Weinberg AM. The risk of injury to the anterior tibial artery in the posterolateral approach to the tibia plateau: a cadaver study. J Orthop Trauma 2013;27:221–5. [13] Newman SD, Mauffrey CP, Krikler S. Distal metadiaphyseal tibial fractures. Injury 2011;42:975–84. [14] Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H. Minimally invasive plate osteosynthesis and vascularity: preliminary results of a cadaver injection study. Injury 1997;28(Suppl 1):A7–12. [15] Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 2002;84:1093–110. [16] Kritsaneephaiboon A, Vaseenon T, Tangtrakulwanich B. Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report. Int Orthop 2013;37:105–11.
Contents lists available at ScienceDirect
Injury j o u r n a l h o m e p a g e : w w w. e l s e v i e r . c o m / l o c a t e / i n j u r y
Minimally invasive posteromedial percutaneous plate osteosynthesis for diaphyseal tibial fractures: technique description Andre Wajnsztejna,*, Robinson Esteves Santos Piresb, Alexandre Leme Godoy dos Santosc, Pedro Jose Labronicid, Helio Jorge Alvachian Fernandese, Mario Ferrettia a
Hospital Israelita Albert Einstein, São Paulo (SP), Brazil Universidade Federal de Minas Gerais, Belo Horizonte (MG), Brazil c Universidade de Sao Paulo, São Paulo (SP), Brazil d Universidade Federal Fluminense (UFF), Niterói (RJ), Brazil e Universidade Federal de São Paulo, São Paulo (SP), Brazil b
K E Y W O R D S
A B S T R A C T
Tibial fractures Fracture fixation Anatomy MIPO
Purpose: The aim of this study was to evaluate the feasibility of performing minimally-invasive plate osteosynthesis (MIPO) in tibial fractures using two posteromedial incisions, and to measure the distance between the plate and neurovascular structures. Materials and methods: We performed nine dissections of specimens that were submitted to tibial MIPO with two posteromedial incisions. One locking compression plate (LCP) of 14 to 16 holes was inserted into the submuscular tunnel in a retrograde manner. Incisions were linked to evaluate the distance between neurovascular structures and the plate. Results: During the proximal incision, a blunt dissection between semitendinosus and medial gastrocnemius tendons, as well as their lateral shift, helped to protect the main local neurovascular structures. In its distal portion, the submuscular plate tunnel insertion and its direction to the proximal incision prevented direct contact and possible damage to neurovascular structures. Moreover, we obtained successful results from a patient submitted to this procedure. Conclusion: Posteromedial MIPO represents a safe and attractive alternative for tibial fractures, particularly if there are damaged soft tissues in the anterior and medial side, or when access to intramedullary osteosynthesis is blocked. © 2017 Elsevier Ltd. All rights reserved.
Introduction
To perform MIPO in the posterior side of the tibia, we combined two techniques: the Lobenhoffer approach for treatment of tibial plateau fractures and the Assal modified tibial pilon posteromedial approach [9,10]. Both techniques are safe, with a low rate of complications. The aim of this study was to evaluate the feasibility of performing MIPO in tibial fractures using two posteromedial incisions, and to measure the distance between the plate and neurovascular structures. This technique can be a treatment option for selected cases, like patients with poor anterior and medial soft tissue condition, peri-implants and periprosthetic fractures, and adolescents with open physis.
Tibial fractures are the most common lesions of long bones. Data from the National Center for Health Statistics indicate an annual prevalence of 492,000 tibial fractures per year in the United States [1]. Open fractures usually occur as a result of high-energy trauma and closed fractures are related to falls and sports accidents. Tibial diaphyseal fractures represent more than 70,000 hospitalisations per year and 800,000 office visits per year in the United States [2–4]. Tibial fractures are usually associated with soft tissues injuries, particularly in the anterior and medial side [5]. Moreover, incision breakdown, skin necrosis and infections are possible outcomes in such fractures [6]. Interlocking intramedullary nail (IMN) and minimally invasive plate osteosynthesis (MIPO) on anterior or medial sides of the tibia are the most common treatment options for diaphyseal tibial fractures [7]. Staged treatment with temporary external fixators can be used until soft tissue conditions are suitable for internal fixation [8]. * Corresponding author. E-mail address: [email protected] (A. Wajnsztejn). 0020-1383/© 2017 Elsevier Ltd. All rights reserved.
Materials and methods Anatomical aspects After approval by the Ethics Committee in Research from the institution, nine legs from five fresh cadavers were dissected. All procedures were realised in ventral decubitus.
A. Wajnsztejn et al. / Injury, Int. J. Care Injured 48S4 (2017) S6–S9
S7
Fig. 2. Posterior view of right leg. Exposure of the Tibial nerve (Tn) on the deep posterior compartment of the leg. Flexor Hallucis Longus (FHL) should be retracted laterally.
Fig. 1. Posterior view of right leg depicting the dissection of the proximal medial approach. Dissection between Medial Gastrocnemius muscle (GTm) and Pes anserinus tendons (Pat).
Proximal approach This surgical technique was developed using the incision described by Galla and Lobenhoffer for the treatment of posteromedial tibial plateau shear fractures [9,11]. Thus, we used as a reference the medial gastrocnemius muscle (GTm) head and the pes anserinus tendons. An 8-cm longitudinal incision at the GTm head was performed, distal to the popliteal fold. After dissecting the subcutaneous tissue, we dissected the fascia in the same direction. Superficial structures between the gastrocnemius heads, such as the small saphenous vein (SSv) and the sural nerve (Sn), were not approached. The dissection was continued medially to the GTm at the interval of semitendinosus tissue (Fig. 1). In a deeper layer, popliteal and soleus muscles were elevated from the bone to enable insertion of the implant. In this deeper dissection, the popliteal artery (Pa) is located between GTm heads. It is divided in the anterior and posterior tibial arteries (ATa and PTa, respectively). The ATa penetrates the posterolateral portion of the interosseous membrane at 46 mm from the joint [12]. As the head of GTm is shifted laterally, the muscle protects all these structures, without any contact with the implant. The tibial nerve (Tn) is a neural structure that remains close to the synthesis material. The plate is inserted underneath the flexor digitorum longus (FDL) and posterior tibial (PT) muscles, protecting the Tn. Also, the posterior tibial vein (PTv) and PTa remain laterally located to the Tn. Distal approach The references for the distal approach are the Achilles tendon and the medial malleolus. The incision starts 1 cm medially to the Achilles tendon and at 8 cm proximally to its insertion, for an
extension of 5 cm. After opening the superficial fascia, the Achilles tendon is shifted to the lateral side. The intermuscular septum that divides superficial and deep compartments is sectioned. We then identify the Tn and the muscular portion of the flexor hallucis longus (FHL) (Fig. 2). An interval between FHL and Tn is developed, exposing the metaphyseal region of the bone, leaving the PTa, the PTv and the Tn protected without traction [10]. The FHL is moved laterally. Submuscular incisions are linked using periosteal elevators. A 4.5-mm locking compression plate (LCP; DePuy Synthes) of 14 to 16 holes was inserted in a retrograde manner after previous modelling (Fig. 3). Finally, to secure the procedure, we connected the incisions (Fig. 4). The shortest distances between the plate and these neurovascular structures were measured using a Vernier calliper with precision of 0.01 mm (Starret Co, Ltda São Paulo, Brazil). Results Proximal approach As SSv and Sn are situated at the superficial layer, we measured the distance from these structures to the incision in the skin. The range of distances between the distal portions of the incision to the Sn was 27.54–38.94 mm (mean, 32.60 mm) and to the SSv was 22.33–34.52 mm (mean, 27.08 mm). From the deepest layer, the distance between the Tn and the implant was 6.3–10.2 mm (mean, 7.9 mm). Distal approach Care was taken to open the intermuscular septum: Tn is located just below the incision. The risk of vascular injury was higher than that of neural injury. The shortest distance between the plate and the Tn was 7.8–21.16 mm (mean, 12.7 mm), whereas the distance between the PTa and implants was 7.6–17.4 mm (mean, 10.6 mm), and the distance between the plate and PTv was 8.3–18.1 mm (mean, 11.6 mm).
S8
A. Wajnsztejn et al. / Injury, Int. J. Care Injured 48S4 (2017) S6–S9
Fig. 3. Posterior view of right leg with a 4.5mm locking compression plate inserted through surgical approaches.
FDL and PT muscle bellies protected neurovascular structures from direct contact with the metallic implant. Discussion There is still no consensus regarding the ideal treatment for shaft and distal tibial fractures [13]. MIPO has been associated with promising results as it permits fracture healing and consolidation with minimal tissue injury or fracture haematoma destruction [14]. MIPO differs from the open reduction method, as the latter promotes more damage to osseous vascularity [15]. Tibial fractures are usually accompanied by soft tissue injuries, which occur in the anterior and medial sides of the leg [8]. On the other hand, the posterior region of the leg has minimal soft tissue injury. Kritsaneephaboon et al. suggested a posterolateral approach for distal tibial fracture osteosynthesis that can be used when anterior soft tissue is compromised [16]. The authors used two posterolateral incisions, at both proximal and distal windows, and the implant site was located in an interval between the FHL and peroneal muscles. The mean distance between the plate and PTa was 4.49 mm. In contrast to the use of two posterolateral incisions suggested by Kritsaneephaboon et al., we advocated two posteromedial incisions for MIPO of tibial fractures. Posterolateral incision is limited by ATa, and cannot be extended proximally. On the other hand, posteromedial incision can be extended proximally to the tibial plateau. Yamamoto et al. published a retrospective case series of posterior tibial MIPO [6]. In their technique, the authors combined a
Fig. 4. Posterior view of right leg after the incisions were connected. Tibial neve (Tn) was marked with a radiopaque thread (*) and distance between the plate and the Tn was measured.
posteromedial distal incision with a posterolateral proximal approach to avoid the anatomical variants in the ATa position. As the plate was inserted in an oblique fashion (inclined), there were anatomical restrictions to increase the stiffness/elasticity of the fixation. We suggest an MIPO technique using two posteromedial windows. We believe that such an approach is easier than the posterolateral approach, as we are able to use longer implants, extending throughout the entire tibial length, possibly leading to alternative surgical options for proximal, diaphyseal and distal tibial fractures. Posteromedial MIPO is not the first choice to treat tibial shaft fractures, but can be a good option for specific cases, such as patients with soft tissue injuries in the anterior and medial sides, or teenagers. Our study has some limitations. We used a small sample of cadaveric specimens, and those specimens did not show any anatomic abnormalities usually seen in fractures. Moreover, the selected implant was bulky and straight and required modelling. Developing specific anatomical implants for such a technique may facilitate the surgical procedure. Therefore, studies with a higher level of evidence and greater sample size are needed to clarify the potential benefits of this surgical technique. Conclusion Taking into account the treatment options for tibial fractures, we consider posteromedial MIPO to be a good alternative technique for selected cases. In vivo studies are necessary to validate this technique.
A. Wajnsztejn et al. / Injury, Int. J. Care Injured 48S4 (2017) S6–S9
Conflict of interest The authors acknowledge that there are no possible conflicts of interest in the manuscript, including financial, consultant, institutional and other relationships that might lead to bias. References [1] Grütter R, Cordey J, Bühler M, Johner R, Regazzoni P. The epidemiology of diaphyseal fractures of the tibia. Injury 2000;31(Suppl 3):C64–7. [2] Clement ND, Beauchamp NJF, Duckworth AD, McQueen MM, Court-Brown CM. The outcome of tibial diaphyseal fractures in the elderly. Bone Joint J 2013;95-B:1255–62. [3] Schmidt AH, Finkemeier CG, Tornetta P. Treatment of closed tibial fractures. Instr Course Lect 2003;52:607–22. [4] Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg Br 1995;77:417–21. [5] Ferguson M, Brand C, Lowe A, Gabbe B, Dowrick A, Hart M, et al. Outcomes of isolated tibial shaft fractures treated at level 1 trauma centres. Injury 2008;39:187–95. [6] Yamamoto N, Ogawa K, Terada C, Okazaki Y, Munetomo K, Noda T, et al. Minimally invasive plate osteosynthesis using posterolateral approach for distal tibial and tibial shaft fractures. Injury 2016;47:1862–6. [7] Vallier HA. Current evidence: plate versus intramedullary nail for fixation of distal tibia fractures in 2016. J Orthop Trauma 2016;30(Suppl 4):S2–S6.
S9
[8] Lavini F, Dall’Oca C, Mezzari S, Maluta T, Luminari E, Perusi F, et al. Temporary bridging external fixation in distal tibial fracture. Injury 2014;45:S58–S63. [9] Galla M, Lobenhoffer P. Der direkte dorsale Zugangsweg zur Versorgung posteromedialer Luxationsfrakturen des Tibiakopfes. Der Unfallchirurg 2003;106:241–7. [10] Assal M, Ray A, Fasel JH, Stern R. A modified posteromedial approach combined with extensile anterior for the treatment of complex tibial pilon fractures (AO/ OTA 43-C). J Orthop Trauma 2014;28:e138–45. [11] Fakler JK, Ryzewicz M, Hartshorn C, Morgan SJ, Stahel PF, Smith WR. Optimizing the management of Moore type I postero-medial split fracture dislocations of the tibial head: description of the Lobenhoffer approach. J Orthop Trauma 2007;21:330–6. [12] Heidari N, Lidder S, Grechenig W, Tesch NP, Weinberg AM. The risk of injury to the anterior tibial artery in the posterolateral approach to the tibia plateau: a cadaver study. J Orthop Trauma 2013;27:221–5. [13] Newman SD, Mauffrey CP, Krikler S. Distal metadiaphyseal tibial fractures. Injury 2011;42:975–84. [14] Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P, Tscherne H. Minimally invasive plate osteosynthesis and vascularity: preliminary results of a cadaver injection study. Injury 1997;28(Suppl 1):A7–12. [15] Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 2002;84:1093–110. [16] Kritsaneephaiboon A, Vaseenon T, Tangtrakulwanich B. Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report. Int Orthop 2013;37:105–11.